HESI Exit Exam 2023 Overview

SPRING 2023 HESI EXIT The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding? A Using salt, herbs, and spices will improve the flavor of foods. B Get an eye examination with an ophthalmologist annually. C Arrange diet schedule around three regular meals a day. D Inspect feet every month for ingrown nails, cuts, and calluses. The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching? B Get an eye examination with an ophthalmologist annually. C Practice using muscle relaxation techniques. A Center attention on positive upbeat music. B Find outlets for more social interaction. C Practice using muscle relaxation techniques. D Think about reasons the episodes occur. The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN? A A 75-year-old client with renal calculi who requires urine straining. C A 30-year-old depressed client who admits to suicide ideation. B A 64-year-old client who had a total hip replacement the previous day. C A 30-year-old depressed client who admits to suicide ideation. D An adolescent with multiple contusions due to a fall that occurred 2 days ago. A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement? B Position bedside table so the client can lean across it. A Raise head of bed until to a 90 degree angle. B Position bedside table so the client can lean across it. C Place bed in a reverse trendelenburg position. D Encourage rest until the analgesic becomes effective. The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action? A Maintain elevated positioning of the dependent joints on affected D Start two large bore IV catheters and review inclusion criteria for side. IV fibrinolytic therapy. B Keep the bed in the lowest position and initiate seizure and fall precautions. C Place an indwelling urinary catheter and measure strict intake and output. D Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has a tonic-clonic seizure that lasts 50 seconds. Following the seizure, the client is lethargic and confused and his wife tells the nurse that her husband has never had a seizure before and has always been alert and communicative. Which action should the nurse take? A Ask the wife to wait outside the room until the nurse can talk with her. 1 / 20 D Explain the postictal state that usually follows seizures. B Keep orienting the client to time and space until he is less confused. C Notify the emergency response team of the client's seizure. D Explain the postictal state that usually follows seizures. The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s)made by the client should the nurse recognize as needing additional education? (Select all that apply.) B Eat more canned vegetables. C Consume foods with saturated fats. A Keep a food diary. B Eat more canned vegetables. C Consume foods with saturated fats. D Walk 30 minutes per day. E Include oatmeal for breakfast. F Use a salt substitute. While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? A Use a water soluble lubricant on affected oral and nasal mucosa. A Use a water soluble lubricant on affected oral and nasal mucosa. B Use a topical lidocaine analgesic for cracked lips. C Ask the mother what she usually uses on the child's lips and nose. D Apply a petroleum jelly to the child's nose and lips. When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? D Check for a distended bladder. A Increase intravenous infusion. B Massage the uterus to decrease atony. C Review the hemoglobin to determine hemorrhage. D Check for a distended bladder. The nurse is caring for a client on the first day postoperative for a descending aortic aneurysm repair. Which assessment finding should the nurse prioritize reporting to the healthcare provider? Reference Range Potassium (Reference Range: 3.5 to 5 mEq/L (3.5 to 5 mmol/L)] B Electrocardiogram ST segment elevation. A Serum potassium 4.8 mEg/L (4.8 mmol/L). B Electrocardiogram ST segment elevation. C Urine output 30 mL/hour. D Blood pressure 130/80. The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicate to the nurse that the client understand the prescribed diet? C Roasted turkey, canned vegetables. A Roast pork, fresh strawberries. B Baked potato with skin, raw carrots. C Roasted turkey, canned vegetables. D Pancakes, whole-grain cereals. The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention? A An 18-year-old client with antisocial behavior who is being yelled A An 18-year-old client with antisocial behavior who is being yelled at by other clients. at by other clients. B A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby. 2 / 20 C A 16-year-old client diagnosed with major depression who refuses to participate in a group. D A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack. A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) is being discharged from a skilled nursing facility. Which action is most important for the nurse to implement? C Provide typed instructions for healthy diet selection A Explain exercise daily regimen. B Demonstrate specific strengthening exercises. C Provide typed instructions for healthy diet selection D Reinforce need for adequate hydration. A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority? A Instruct parents regarding care of the incisional area. B Mark an outline of the "olive-Shaped" mass in the right epigastric area. C Initiate a continuous infusion of IV fluids per prescription. D Monitor amount of intake and infant's response to feedings. NGN: The client is a 26 yr old female who was in a car accident 6 months ago that killed her mother, husband, and 2 yr old son. She and her father were the only survivors of the crash. She is seeking care for depression. Choose the most likely options for the information missing from the statement by selecting from the list of options provided. C Initiate a continuous infusion of IV fluids per prescription. The client is exhibiting symptoms of PTSD relating to EXPERIENCING A LIFE-THREATENING EVENT and LOSING A LOVE ONE. The client is exhibiting symptoms of _________ relating to ___________ and __________. NGN: After the examination by the physician, the client was diagnosed with depression and PSTD. The physician wrote orders for medication that need to be filled. The nurse speaks with the client again to educate her about her diagnose and medication. How can the nurse build a therapeutic relationship with the client? Select all that apply. A The nurse can establish a meaningful connection B The nurse can be open, honest, and sincere A The nurse can establish a meaningful connection C The nurse can communicate acceptance of the client as she is B The nurse can be open, honest, and sincere C The nurse can communicate acceptance of the client as she is D The nurse can talk as much as needed to get the client talking E The nurse can focus energy on the client F The nurse can show no emotion when talking to the client NGN: During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash. Choose the most likely options for the information missing The statement by the client represents SUICIDAL IDEATION and from the statement by selecting the list of options provided. should be followed up with AN ASSESSMENT OF RISK FACTORS FOR SUICIDE. The statement by the client represents _______ and should be followed up with __________. NGN: What would be some effective strategies that the nurse could use to decrease the client's risk of suicide in the future? Select all that apply. A Have the client sign a no-suicide contract F Help the client enlist the help of friends and family A Have the client sign a no-suicide contract B Refer the client for cognitive behavioral therapy C Make the client feel too guilty to commit suicide D Place the client in a locked unit 3 / 20 E Have the client remove any sharp objects from the home F Help the client enlist the help of friends and family Dopamine 5 mcg/kg/minute IV is prescribed for a client who weighs 132 pounds. The pharmacy dispenses a 500 mL IV solution of 0.9% normal saline with dopamine 1600 mg. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numeric value only. If rounding is required, round to the nearest tenth.) An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? Reference Range: Blood alcohol level [Reference Range: 0 to 10.9 mmol/L (0% to 0.05%)] Lithium (Reference Range: 0.8 to 1.2 mEq/L or 0.8 to 1.2 mmol/L] B Serum lithium level of 1.6 mEq/L (1.6 mmol/L) A Blood alcohol level of 0.09% (90 mmol/L) B Serum lithium level of 1.6 mEq/L (1.6 mmol/L) C Six hours of sleep in the past three days. D Weight loss of 10 pounds (4.5 kg) in past month. A male client reports to the on-call clinic nurse that he took tadalafil 10mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. What action should the nurse take? A Tell the client to have someone bring him to an emergency department immediately. B Instruct the client to increase his intake of oral fluids until the skin flushing is relieved. C Reassure the client that skin flushing is a common side effect of the medication. D Advise the client to place one nitroglycerin tablet under his tongue as a precaution. C Reassure the client that skin flushing is a common side effect of the medication. An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. Which percentage of body surface area should the nurse document in the electronic medical record (EMR)? B 36%. A 9%. B 36%. C 18%. D 45 %. An unlicensed assistive personnel (UP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UP's behavior? (Place the actions in order from first on top to last on bottom.) 1 Note date and time of the behavior. 2 Discuss the issue privately with the UAP. 3 Plan for scheduled break times. 4 Evaluate the UP for signs of improvement. What nursing intervention is particularly indicated for the second stage of labor? A Assessing the fetal heart rate and pattern for signs of fetal distress. B Monitoring effects gf oxytocin administration to help achieve cervical dilation. C Providing pain medication to increase the client's tolerance of labor pains. D Assisting the client to push effectively so that expulsion of the fetus can be achieved. D Assisting the client to push effectively so that expulsion of the fetus can be achieved. 4 / 20 A child with peripheral edema who weighs 44 pounds receives a prescription for furosemide 2 mg/kg intravenously every 12 hours. The vial is labeled, "10 mg/mL." How many mL should the nurse administer? (Enter numeric value only.) 4 mL Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)? A Erythrocytes, hemoglobin, and hematocrit. B Serum potassium, calcium, and phosphorus. C Blood pressure, heart rate, and temperature. D Leukocytes, neutrophils, and thyroxine. B Serum potassium, calcium, and phosphorus. A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement? B Redress the abdominal incision A Leave the lights on in the room at night. B Redress the abdominal incision C Apply soft bilateral wrist restraints. D Replace the IV site with a smaller gauge. The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? A Begins to show signs of improvement in effect. A Begins to show signs of improvement in effect. B Expresses feelings of sadness and loneliness. C Neglects personal hygiene and has no appetite. D Lacks interest in the activities of family and friends. NGN: The client is a 42 yr old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1. The nurse is discussing the client's pain management with a student nurse. Morphine is a(n) AGONIST-ANTAGONIST OPIOD and it activates BETA receptors and is used to relieve PAIN. Choose the most likely options for the information missing from the statement (s) by selecting from the lists of options provided. Morphine is a(n) __________ and it activates __________ receptors and is used to relieve _________. NGN: The client is a 42 yr old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1. What actions should the nurse take to assure safety during morphine administration? Select all that apply. A Have a manual resuscitation bag at the bedside B Ask the client about other medications she takes C Perform a 12-lead electrocardiogram D Take an initial respiratory rate E Suction the client to clear the airway F Restrain the client with soft restraints NGN: The client is a 42 yr old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1. 5 / 20 B Ask the client about other medications she takes D Take an initial respiratory rate What other medications would the nurse expect the surgeon to prescribe along with Morphine? Select all that apply. A Docusate sodium B Methadone C Propofol D Naloxone E Senna F Ibuprofen A Docusate sodium D Naloxone NGN: The client is a 42 yr old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1. The charge nurse places a fall precautions sign on the client's door. What side effects of Morphine could contribute to this client's fall risk? Select all that apply. C Orthostatic hypotension D Sedation G Euphoria A Urinary retention B Seizures C Orthostatic hypotension D Sedation E Nausea F Itching G Euphoria An older client with a history of cataracts is recovering from intraocular lens implant (OL) surgery to the left eye. During the post-procedure period, which intervention should the nurse implement? C Provide an eye shield to be worn while sleeping. A Encourage deep breathing and coughing exercises. B Obtain vital signs every 2 hours during hospitalization. C Provide an eye shield to be worn while sleeping. D Teach a family member to administer eye drops. An adult client is admitted to the critical care unit with systemic inflammatory response syndrome (SIRS) as a result of a postbur infection. The client has a long line peripherally inserted IV catheter for fluid and medication administration and current vital signs include temperature 102.8° F (39.3° C), heart rate 108 beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first? A Provide bedside equipment for transmission and protective precautions. B Culture sputum, urine, burn wound, and all intravenous access sites. C Implement central line-associated bloodstream infection (CLABSI) protocols. D Evaluate daily serum electrolytes and hydration status. B Culture sputum, urine, burn wound, and all intravenous access sites. Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client may have had a pulmonary embolus. Which action should the nurse take first? D Provide supplemental oxygen. A Bring the emergency crash cart to the bedside. B Prepare a continuous heparin infusion per protocol. C Notify the healthcare provider. D Provide supplemental oxygen. The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4 mL.". How many mL should 6 / 20 the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.) 0.2 mL In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider? A Watery diarrhea. A Watery diarrhea. B Increased fatigue. C Yellow-tinged sputum. D Nausea and headache. The nurse observes an unlicensed assistive personnel (UP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take? A Instruct the UP to return to the client's room to perform hand washing. D Remind the UAP to continue rubbing the hands together until B Advise the UP to wear gloves when obtaining vital signs for all they are dry. clients. C Supervise the UP in the next client's room to evaluate hand hygiene. D Remind the UAP to continue rubbing the hands together until they are dry. The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.) A Perform daily surgical dressing change for a client who had an abdominal hysterectomy. B Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). C Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperatively. D Start the second blood transfusion for a client twelve hours following a below knee amputation. E Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty. A Perform daily surgical dressing change for a client who had an abdominal hysterectomy. B Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). E Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty. Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter? B Observe insertion site. A Assess perineal area. B Observe insertion site. C Palpate flank area. D Measure abdominal girth A client with cancer develops tumor lysis syndrome (TLS) following chemotherapy. Which nursing action has the highest priority in responding to the symptoms of this syndrome? C Maintain intravenous therapy. A Instruct the client to take analgesics on a regular schedule. B Encourage the client to verbalize anxiety and grief. C Maintain intravenous therapy. D Identify potential sources of infection. NGN: The client is 74 yr old female with a hx of HTN and HLD. She takes lisinopril, simvastatin, and melatonin for sleep. She was admitted today for pneumonia. She visited her PCP last week, and she has lost 2.8kg since that visit. Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing. 7 / 20 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress. 1 Potential Condition: dehydration, malnutrition, hypoxia, CVA Potential Condition: dehydration Actions to take: Measure BP and Ask the client for a nutrition hx 2 Actions to take: Measure BP, ask the client for a nutrition hx, perform chest physParameters to monitor: Capillary refill and BG iotherapy, encourage the client to drink, administer O2 2 Parameters to monitor: Capillary refill, BG, pupil size, albumin level The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having sex with someone who had many partners. Which response should the nurse provide? A Inform that follow-up may end after the treatment is finished. D Remain non-judgmental and assure the client of confidentiality. B Emphasize that using safe sex practices removes the risk of STIs. C Clarify that all STIs are transmitted through sexual intercourse. D Remain non-judgmental and assure the client of confidentiality. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg PO twice daily. Which information should the nurse include in this client's teaching plan? (Select all that apply.) A Report persistent polyuria to the healthcare provider. C Take metformin with the morning and evening meal. D Recognize signs and symptoms of hypoglycemia. A Report persistent polyuria to the healthcare provider. B Use sliding scale insulin for fingerstick glucose elevations. C Take metformin with the morning and evening meal. D Recognize signs and symptoms of hypoglycemia. E Take an additional dose for signs of hyperglycemia. A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? D The client's need for pain medication should be determined. A The nurse manager should be updated on the client's status. B The client's status should be conveyed to the chaplain. C The impending signs of death should be documented. D The client's need for pain medication should be determined. A 46-year-old male client who had a myocardial infarction (MI) 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse included in the plan of care? D. Ineffective coping related to denial. A Anxiety related to treatment plan. B Decisional conflict due to stress. C Deficient knowledge of lifestyle changes. D. Ineffective coping related to denial. A client receives a prescription for norepinephrine 3 mcg/min IV. The IV bag is contains norepinephrine 4mg in dextrose 5 % in water 1000mL. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only). The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention? A Circumferential skin irritation. 8 / 20 B Red streak tracking the vein. B Red streak tracking the vein. C Cool sensation above the site. D A sluggish blood return. A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the cent. Which action should the nurse take? A Remind the UP to apply a fitted respirator mask before entering D Review the need for the UP to wear a face mask while in close the client's room. contact with the client. B Assign the UP to provide care for another client and assume full care of the client. C Instruct the UP to notify the nurse of any changes in the client's respiratory status. D Review the need for the UP to wear a face mask while in close contact with the client. An older adult with terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. Which intervention(s) should he nurse include in this client's plan of care? (Select all that apply). A Record the client's desire to live. B Teach client how to use guided imagery. C Instruct client and family to reconsider end of life choices. D Encourage family to bring the client old photographs. E Encourage family to visit frequently. While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement? B Teach client how to use guided imagery. D Encourage family to bring the client old photographs. E Encourage family to visit frequently. A Administer a nebulizer treatment. A Administer a nebulizer treatment. B Call for an Ambu resuscitation bag. C Increase oxygen to 6 liters/minute. D Assist the client to lie back in bed. A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to include in the assessment of this client? A "What are the voices saying?" A "What are the voices saying?" B "Which medication works best?" C "When do you hear voices?" D "How do you cope with the voices?" A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet? A Avoid eating all foods that contain any vitamin K because it is an antagonist of warfarin. C Eat approximately the same amount of leafy green vegetables B Increase the intake of dark green leafy vegetables while taking daily so the amount of vitamin K consumed is consistent. warfarin. C Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. D Eat two servings of raw dark green leafy vegetables daily and continue for 30 days after warfarin therapy is completed. The daughter of an older woman who has Parkinson's disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.) 9 / 20 A Encourage increased intake of high protein foods. B Instruct the daughter to check her mother's temperature. C Determine if the mother has recently experienced a fall. D Ask if the mother is experiencing any pain with urination. E Review the client's current food and medication allergies. B Instruct the daughter to check her mother's temperature. C Determine if the mother has recently experienced a fall. D Ask if the mother is experiencing any pain with urination. The nurse is preparing a 4-day-old infant with a serum bilirubin level of 19 mg/dI (325 Mcmol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? Reference Range Total Bilirubin [Reference Range: Newborn:0.1 to 10.5 mg/dL (1.7 to 180 Mcmol/L)] D Reposition the infant every 2 hours. A Cover with a receiving blanket. B Perform diaper changes under the light. CFeed the infant every 4 hours. D Reposition the infant every 2 hours. The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet? D Low fat dairy products. A Fresh fruits and vegetables. B Iron-rich meats. C Water and herbal teas. D Low fat dairy products. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. Which action should the nurse take first? B Explore client's readiness to discuss the situation. A Report the finding to the police department. B Explore client's readiness to discuss the situation. C Determine the frequency and type of client's abuse. D Discuss treatment options for abusive partners. When conducting an admission assessment, the nurse notes that an adult female client has developed two new allergies since her last admission. The client describes herself as lactose intolerant and states that she is unable to eat eggs. Which intervention(s) should the nurse implement? (Select all that apply.) B Add egg allergy to client's identification arm band. D Notify the dietary department of the client's egg intolerance. A Ask the client to describe her reaction to milk and eggs. E Enter new allergy information in the client's electronic medical B Add egg allergy to client's identification arm band. record. C Eliminate the chicken selections from the client's menu. D Notify the dietary department of the client's egg intolerance. E Enter new allergy information in the client's electronic medical record. NGN: The client is a 49 yr old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the ED last night when he was having more difficulty breathing. He has a hx of one-half pack a day of cigarette smoking for 20 yrs. He has no significant medical or surgical hx. B Place the client on a cardiorespiratory monitor F Start O2 3L via NC What 2 orders should the nurse complete first? A Sputum culture B Place the client on a cardiorespiratory monitor C Start a PIV D NPO E Acetaminophen 350mg PO q6h for temperature greater than 10 / 20 101F F Start O2 3L via NC G Chest x-ray H Normal saline 150 mL/hr NGN: The client is a 49 yr old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the ED last night when he was having more difficulty breathing. He has a hx of one-half pack a day of cigarette smoking for 20 yrs. He has no significant medical or surgical hx. To start the client on oxygen as ordered, what should the nurse collect from the supply room? Select all that apply. B Flowmeter G Nasal cannula A Sterile water B Flowmeter C Lamb's wool D Suction canister E Humidifier bottle F Tape G Nasal cannula NGN: The client is awake and alert but restless. He states "I am feeling extremely anxious right now." The client has decreased breath sounds in the left lower lobe. His mucus membranes are dry. He has a productive cough with thick, yellow secretions. His capillary refill is 4 seconds. Heart rate 101 bpm. Oxygen saturation 90%. Blood pressure 145/89 mmHg. Temperature 100.2F. Respiratory rate 28 bpm. The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and document it in the chart For each body system, click to specify the assessment findings that indicates hypoxia. Respiratory A Respiratory rate 28 bpm B Productive cough C Oxygen saturation 90% Respiratory A Respiratory rate 28 bpm C Oxygen saturation 90% Cardiovascular A Heart rate 101 bpm C Capillary refill 4 seconds Cardiovascular A Heart rate 101 bpm B BP 145/89 mmHg C Capillary refill 4 seconds NGN: The client is a 49 yr old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the ED last night when he was having more difficulty breathing. He has a hx of one-half pack a day of cigarette smoking for 20 yrs. He has no significant medical or surgical hx. Drag from the choices below to fill in each blank in the following sentence. The nurse should place the client in a SEMI-FOWLER'S position to promote LUNG EXPANSION. The nurse should place the client in a ANSWER 1 position to promote ANSWER 2. Answer 1: trendelenburg, supine, prone, or semi-folwer's Answer 2: venous return, gastric motility, skin integrity, or lung expansion 11 / 20 A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain? D Level of consciousness. A Blood glucose level. B Percussion of abdomen. C Serum electrolytes. D Level of consciousness. ) A male client is admitted for the removal of an internal fixation device that was inserted for a fractured ankle. During the client's admission history, he tells the nurse that he recently received vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action(s) should the nurse take? (Select all that apply.) A Collect multiple site screening cultures for MRSA. B Place the client on contact transmission precautions. E Continue to monitor the client for signs of an infection. A Collect multiple site screening cultures for MRSA. B Place the client on contact transmission precautions. C Call healthcare provider for a prescription for linezolid. D Obtain a sputum specimen for culture and sensitivity. E Continue to monitor the client for signs of an infection. An older client admitted for observation following a fall while getting out of the bath tub becomes increasingly confused. The family arrives with the home medication list and the client's healthcare power of attorney. When providing a report to the healthcare provider using BAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first? A Increasing confusion of the client. A Increasing confusion of the client. B Client's healthcare power of attorney. C Fall at home as reason for admission. D Currently prescribed medications. A nurse took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the impaired nurse has asked nursing administration to allow return to work. When the nurse administrator approaches the charge nurse with the impaired nurse's request, which action is best fo the charge nurse to take? B Allow the impaired nurse to return to work and monitor medicaA Meet with staff to assess their feelings about the impaired tion administration. nurse's return to the unit. B Allow the impaired nurse to return to work and monitor medication administration. C Ask to meet with the impaired nurse's therapist before allowing the nurse back on the unit. D Since treatment is completed, assign the nurse to routine R responsibilities. When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take? A Explain to the client that the dosage has been changed. B Tell him to take the medication then verify the dosage at the next healthcare team meeting. C Withhold the medication until the dosage can be confirmed. D Inform him that he may refuse the medication and document whether or not he takes it C Withhold the medication until the dosage can be confirmed. A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention (s) should the nurse implement? (Select all that apply.) 12 / 20 A Report serum albumin and globulin levels. B Provide diet low in phosphorus. C Increase oral fluid intake to 1,500 mL daily. D Note signs of swelling and edema. E Monitor abdominal girth. A Report serum albumin and globulin levels. D Note signs of swelling and edema. E Monitor abdominal girth. After receiving report, the nurse can most safely plan to assess which client last? A An adult client with no postoperative drainage in the Jackson-Prat drain with the bulb compressed. B An older client with a distended abdomen and no drainage from the nasogastric tube. C An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac D An adult client with a rectal tube draining clear, pale red liquid drainage. A An adult client with no postoperative drainage in the Jackson-Prat drain with the bulb compressed. Which intervention Is most important for the nurse to include in the plan of Care for a client who is 12 hours post-thyroidectomy ? A Resume antithyroid drug therapy. B Prepare to administer radioactive iodine treatments. C Anticipate and monitor for hypothermia. D Maintain a semi-Fowler position. A Resume antithyroid drug therapy. A preschool-aged child who is being treated for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that the child is experiencing a reaction to the toxins that are created by the Streptococcus bacteria? B White coating on tongue. A Red bumps across chest. B White coating on tongue. C High, protracted fever. D Flaky, peeling skin. The nurse is caring for a client with a fractured femur. Following removal of traction and the application of a full-leg cast, which action should the nurse prioritize? D Neurovascular checks. A Leg elevation. B Pain management. C Ambulation teaching. D Neurovascular checks. Which environmental factor is most significant when planning care for a client with osteomalacia? A Cool, moist air. B Stimulating sounds and activity. C Quiet, calm surroundings. D Adequate sunlight. D Adequate sunlight. A client who weighs 176 pounds receives a prescription for enoxaparin sodium 1.5 mg/kg/day subcutaneously. The medication is available in 120 mg/0.8 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.) 0.8 mL What action should the school nurse implement to provide secondary prevention for school-aged children? A Initiate a hearing and vision screening program for first graders. A Initiate a hearing and vision screening program for first graders. B Prepare a presentation on how to prevent the spread of lice. C Observe a person with type 1 diabetes self-administer a dose 13 / 20 of insulin. D Collaborate with a science teacher to prepare a health lesson. An older client recently transferred to a rehabilitation facility after aortic valve replacement surgery is experiencing anxiety and difficulty adjusting to the transition. The healthcare provider prescribes an antidepressant and a mild sedative for sleep. Which intervention is most important for the nurse to include in client's plan of care? C Obtain a blood pressure reading before client gets out of bed. A Measure and record the client's urinary output every day. B Provide the client with teaching regarding a cardiac diet. C Obtain a blood pressure reading before client gets out of bed. D Obtain client's vital signs every 4 hours when awake. The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication? A Push the undiluted Dextrose slowly through the currently infus- A Push the undiluted Dextrose slowly through the currently infusing IV. ing IV. B Dilute the Dextrose in one liter of 0.9% Normal Saline solution. C Mix the Dextrose in a 50 mL piggyback for a total volume of 100 mL. D Ask the pharmacist to add the Dextrose to a TPN solution. The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond? A Suggest that the child be encouraged to participate in a team D Encourage the parents to allow the child to continue attending sport to encourage socialization. swimming lessons with supervision. B Explain that their child is too young to understand the risks associated with swimming. C Provide a list of alternative activities that are less likely to cause the child to experience fatigue. D Encourage the parents to allow the child to continue attending swimming lessons with supervision. A male client admitted with chronic pulmonary obstruction disease (COPD) exacerbation is receiving assisted ventilation with continuous positive airway pressure (CPAP). His vital signs are: temperature 98.8 °F (37.1 °C), heart rate 118 beats/minute, respirations 46 breaths/minute, blood pressure 176/92 mmHg. While completing the pulmonary assessment, his oxygen saturation reading is 78% and he is difficult to arouse. Which action should the nurse implement? A Prepare for rapid sequence intubation. A Prepare for rapid sequence intubation. B Increase the oxygen delivery by 10%. C Administer PRN nebulizer treatment. D Complete neurological assessment. A client is admitted to the hospital after experiencing a stroke or cerebrovascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? B Persistent coughing while drinking. A Inappropriate or exaggerated mood swings. B Persistent coughing while drinking. C Abnormal responses for cranial nerves I and Il. D Unilateral facial drooping. A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implements while administering this medication? 14 / 20 A Measure urinary output every hour. B Initiate seizure precautions. C Monitor serum potassium frequently. D Assess pupillary response to light hourly A Measure urinary output every hour. The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions? A Twin siblings admitted with scarlet fever that is complicated with D A client with a positive Mantoux and sputum cultures results pneumonia. positive for AFB. B An older client with scabies who is admitted from an extended care facility. C A female adolescent admitted with multiple genital Herpes simplex I lesions. D A client with a positive Mantoux and sputum cultures results positive for AFB. The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include? B Ensure that the infant's crib mattress is firm. A Prop the infant with a pillow when in a side-lying position. B Ensure that the infant's crib mattress is firm. C Place the infant in a prone position whenever possible. D Swaddle the infant in a blanket for sleeping. Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium? B Maintain a quiet, non-stimulating environment. A Confront the client's denial of substance abuse. B Maintain a quiet, non-stimulating environment. C Force oral fluids and provide frequent small meals. D Encourage attendance and group participation. A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next? A Remove the catheter and palpate the client's bladder for residual distention. B Clamp the catheter for thirty minutes and then resume draining. C Remove the catheter and replace it with an indwelling catheter. D Allow the bladder to empty completely or up to 1,000 mL of urine. D Allow the bladder to empty completely or up to 1,000 mL of urine. NGN: Client was brought in for his 5 yr old well visit and to update vaccines. The mother reports that the child is having some trouble paying attention in school and has had a poor appetite in the past few weeks. Which intervention is appropriate to manage the lead poisoning level of 7ug/dL (0.34umol/L). Each row must have at least one, but may have more than one, response option selected. Monitor H&H for potential anemia.- NOT NEEDED Monitor blood lead levels at 1 month, then every 3-4 months.NEEDED Chelation therapy.- NEEDED Provide family with lea education, regular developmental and behavioral surveillance, and social service referral if necessary.Monitor h&H for potential anemia. NEEDED Monitor blood lead levels at 1 month, then every 3-4 months. Ask parent about the age of their home and any home remedies Chelation therapy. that may have been taken.- NEEDED Provide family with lea education, regular developmental and Providing supplemental oxygen.- NEEDED behavioral surveillance, and social service referral if necessary. Monitor urine glucose and protein for renal effects of lead.- NOT Ask parent about the age of their home and any home remedies NEEDED that may have been taken. 15 / 20 Providing supplemental oxygen. Monitor urine glucose and protein for renal effects of lead. A male client with heart failure becomes short of breath, anxious, and has audible wheezing with sputupink frothy m. The nurse sits the client upright and provides oxygen per nasal cannula. The nurse receives a prescription to administer a one-time dose of morphine sulfate intravenously. What action should the nurse take? D Review the need for the prescription with the healthcare provider. A Consult with the charge nurse regarding the morphine prescription. B Administer the dose of morphine sulfate as prescribed. C Withhold the morphine until the client's dyspnea resolves. D Review the need for the prescription with the healthcare provider. A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother? A Withhold this dose. A Withhold this dose. B Mix the next dose with food. C Give another dose. D Administer a half dose now A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available to use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/dL (15 g/L). Which intervention is the priority for the nurse to implement? Reference Range: Serum Albumin [Reference Range: 3.5 to 5.5 g/dL (35 to 55 g/L)]. B Ensure the client receives frequent small meals containing complete proteins. A Evaluate patency of the AV graft for resumption of hemodialysis. B Ensure the client receives frequent small meals containing complete proteins. C Instruct the client to continue to follow the prescribed rigid fluid restriction amounts. D Recommend the use of support stockings to enhance venous return. The nurse is assigning care of a client with prostatitis to a practical nurse (P). Which instruction should the nurse provide the PN regarding care of this client? D Avoid urinary catheterization. A Restrict oral fluid intake. B Strain all urine. C Maintain contact isolation. D Avoid urinary catheterization. The nurse observes an unlicensed assistive personnel (UP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take? C Confirm that the gown is tied securely at the neck and waist. A Help the UAP reposition the gown sleeve over the glove edges. B Remind the UP to wash hands frequently while in the room. C Confirm that the gown is tied securely at the neck and waist. D Assist the UAP with application of a face mask or face shield. 16 / 20 A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide? B This hernia is a normal variation that resolves without treatment. A Restrictive clothing will be adequate to help the hernia go away. B This hernia is a normal variation that resolves without treatment. C The quarter should be secured with an elastic bandage wrap. D An abdominal binder can be worn daily to reduce the protrusion. At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client? D Anxiety. A Knowledge deficit. B Pain (acute). C Anticipatory grieving. D Anxiety. 112) An adult male client reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is a vegetarian, and takes atenolol which maintains his blood pressure at 130/74 mm hg. Which risk factors should the nurse explore further with the client? (SATA) A History of hypertension. E Family health history. A History of hypertension. B Homosexual lifestyle. C Vegetarian diet. D Excessive aerobic exercise. E Family health history. The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.) A Sodium intake can be regulated by limiting canned foods in the diet. B Salt substitutes can help with maintaining a healthy diet. C Alcohol consumption will not produce vascular changes. D Uncontrolled hypertension can lead to renal damage. E Blood pressure readings should be taken at noontime. F Weight management is promoted by taking daily walks for thirty minutes. A Sodium intake can be regulated by limiting canned foods in the diet. B Salt substitutes can help with maintaining a healthy diet. D Uncontrolled hypertension can lead to renal damage. F Weight management is promoted by taking daily walks for thirty minutes. A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which Intervention should the nurse provide to address the client's problem? B Arrange an appointment with a pain specialist. A Contact a hospice nurse for an evaluation. B Arrange an appointment with a pain specialist. C Form an interdisciplinary team for evaluation. D Ask for a consultation with a psychologist. Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first? A Obtain a capillary glucose level. B Feed 30 mL of 10% dextrose in water. C Wrap tightly In a warm blanket. D Encourage the mother to breastfeed. A Obtain a capillary glucose level. 17 / 20 A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take? C Keep chest tube container below the site of insertion. A Secure chest tube to the stretcher for transport. B Administer PRN pain medication prior to transport. C Keep chest tube container below the site of insertion. D Mark the amount of chest drainage on the container. The nurse receives a shift report about a male client with obsessive-compulsive disorder. The nurse completes morning rounds and approaches the client while he is repeatedly washing the top of the same table. Which intervention should the nurse implement? A Allow time for the behavior and then redirect the client to other A Allow time for the behavior and then redirect the client to other activities. activities. B Teach the client thought stopping techniques and ways to refocus behaviors. C Assist the client to identify stimuli that precipitates the activity. D Encourage the client to be calm and relax for a little while. The healthcare provider prescribes regular insulin 8 units/hr intravenously (IV). The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only.) 0.08 mL/hr Place the red dot on the base of the neck To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Image: click on the location) The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3-year-old son for wetting his pants. What initial action should the nurse take? D Provide disposable training pants while calming the mother. A Inform the mother that toilet training is slower for boys. B Refer the mother to a community parent education program. C Suggest that the mother consult a pediatric nephrologist. D Provide disposable training pants while calming the mother. When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRS)? A When the client has ankle edema. B During admission to labor and delivery. C If the client has an elevated blood pressure. D Within the first trimester of pregnancy. C If the client has an elevated blood pressure. Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider? A A client is walking the halls at night rubbing his hands together. D A disoriented client removed the mesh wrapped IV line for the B A family member expresses concern about their relative "picksecond time. ing" at the NG tube. C A16-year-old boy swung his fist at the nurse. D A disoriented client removed the mesh wrapped IV line for the second time. 18 / 20 AUDIO OF LUNG SOUNDS: The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.) C Stridor A High pitched wheeze B Low pitched or coarse crackles C Stridor D High pitched or fine crackles VIDEO OF G-TUBE The charge nurse observes a new nurse demonstrate the administration of two different liquid medications through a gastrostomy tube used for continuous feedings, as seen in the video. Which action(s) should the charge nurse take? (Select all that apply) C Confirm that the nurse determined the amount of gastric residual. A Advise the nurse to use the plunger when giving medications. D Instruct the nurse to administer each medication separately. B Encourage the nurse to flush the tube with more water. E Add the liquid volumes when documenting fluid intake. C Confirm that the nurse determined the amount of gastric residual. D Instruct the nurse to administer each medication separately. E Add the liquid volumes when documenting fluid intake. An adult women who was recently diagnosed with type 2 DM is seen in the clinic for lab tests. The cline's height is 5 ft 2 in and weight 165 lbs. Her recent lab findings are described above. In planning nutrition teaching for this client, which diet modification(s) should the nurse recommend? (Select all that apply) A Decrease processed carbohydrate in diet. B Increase dietary fiber such as whole grain. C Reduce daily fat intake to 10% of total calories. D Eliminate alcohol intake except for special occasions. E Restrict protein to 10% of total calories in diet. A Decrease processed carbohydrate in diet. B Increase dietary fiber such as whole grain. D Eliminate alcohol intake except for special occasions. A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? B Hemoglobin. A Serum calcium. B Hemoglobin. C Osmolality. D Erythrocyte sedimentation rate. A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? A Current diagnosis of hepatitis B. A Current diagnosis of hepatitis B. B History of intravenous drug abuse. C Length of time of the exposure to tuberculosis. D Conversion of the client's PPD test from negative to positive. 129) A client with obstructive sleep apnea (OSA) ambulates in the hallway with the nurse prior to bedtime and intervention is most important for the nurse to implement before leaving the client? A. Apply the client's positive airway pressure device. A. Apply the client's positive airway pressure device. B Elevate the head of the bed to a 45 degree angle. C Lift and lock the side rails in place. D Remove dentures or other oral appliance. The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UP). Which task should the nurse assign to the PN? 19 / 20 A Determine the need for urinary catheterizations. B Titrate oxygen to prescribed parameters. C Evaluate and update plans of care for clients. D Receive a postoperative client and conduct the assessment B Titrate oxygen to prescribed parameters. The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below the knee amputation and pedal pulses that are weak and thready. What action should the nurse take? A Document that an accurate oxygen saturation reading cannot be obtained. B Elevate to client's hands for five minutes prior to obtaining a reading from the finger. C Increase the oxygen based on the client's breathing patterns and lungs sound. D Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading. An unlicensed assistive personnel (UAP) is assigned to provide care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? D Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading. C Advice the client to maintain bedrest so that safety can be ensured. A Determine the client's level of mobility and need for assistance. B Instruct the UAP that all clients deserve equal care. C Advice the client to maintain bedrest so that safety can be ensured. D Assigned another UAP to care for the client. 20 / 20