HESI EXIT NGN, HESI RN EXIT EXAM FULL
QUESTIONS WITH ANSWERS
The nurse is wearing personal protective equipment while caring for a pt. When exiting the r
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
oom, which PPE should be removed first? - ans-Gloves
xz xz xz xz xz xz xz xz
An older pt is brought to the ED with a sudden onset of confusion that occurred after experie
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ncing a fall at home. The daughter, who has power of attorney, has brought the client's pres
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
criptions. Which information should the nurse provide first when reporting to the healthcare
xz xz xz xz xz xz xz xz xz xz xz xz xz
provider using SBAR communication? - ans-Increasing confusion of the pt.
xz xz xz xz xz xz xz xz xz
A pt presses the call bell and requests pain medication for a severe headache. To assess th
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e quality of the pt. Pain, which approach should the nurse use? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
Ask the patient to describe the pain
xz xz xz xz xz xz
A pt tells the nurse about working out with a personal trainer and swimming three times a we
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ek in an effort to lose weight and sleep better. The pt states that it still is taking hours to fall a
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
sleep at night. Which action should the nurse implement? - ans-
xz xz xz xz xz xz xz xz xz xz
Ask the pt for a description of the exercise schedule that is being followed
xz xz xz xz xz xz xz xz xz xz xz xz xz
2 days prior to discharge from the rehab facility, the nurse is teaching a pt who is recovering
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
from Guillain- xz
Barre syndrome about home. Which actions should the nurse include when providing disch
xz xz xz xz xz xz xz xz xz xz xz xz
arge teaching to the pt and spouse? SATA - ans--review safe transfer strategies
xz xz xz xz xz xz xz xz xz xz xz xz
-develop a nutritional plan xz xz xz
-help identify community support
xz xz xz
The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clin
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ic. Which outcome indicates that the program was effective? - ans-
xz xz xz xz xz xz xz xz xz xz
pt who develop disease complications promptly received rehabilitation
xz xz xz xz xz xz xz
The nurse has received funding to design a health promotion project for African American w
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
omen who are at risk for developing breast cancer. Which resource is most important in des
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
igning this program? - ans-participation of community leaders in planning the program
xz xz xz xz xz xz xz xz xz xz xz
A pt with multiple injuries is being treated in the burn trauma unit just hours after the injuries
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
occurred. The healthcare provider instructs the nurse to avoid auto contamination when pe
xz xz xz xz xz xz xz xz xz xz xz xz
rforming dressing changes. Which intervention is most important for the nurse to implemen
xz xz xz xz xz xz xz xz xz xz xz xz
t? - ans-use gown, mask, and gloves with dressing changes
xz xz xz xz xz xz xz xz xz
A pt is recovering in the critical care unit following a cardiac cath. IV nitro and heparin are inf
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
using. The pt is sedated but responds to instructions. After changing positions, the pt compl
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
,ains of pain at the right groin insertion site. What action should the nurse implement? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Stimulate the pt to take deep breaths xz xz xz xz xz xz
Prior to obtaining a trapeze bar for a pt with limited mobility, which pt assessment is most im
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
portant for the nurse to obtain? - ans-upper body muscle strength
xz xz xz xz xz xz xz xz xz xz
While the nurse is assessing an older pt fall risk, the pt reports living at home alone and nev
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
er falling. Which action should the nurse take? - ans-
xz xz xz xz xz xz xz xz xz
Continue to obtain pt data needed to complete the fall risk survey xz xz xz xz xz xz xz xz xz xz xz
The nurse is feeding an older adult who was admitted with aspiration pneumonia. The pt is
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
weak and begins coughing while attempting to drink through a straw. Which intervention sh
xz xz xz xz xz xz xz xz xz xz xz xz xz
ould the nurse implement? - ans-Teach coughing and deep breathing exercises
xz xz xz xz xz xz xz xz xz xz
The nurse is teaching the pt about home care after surgery for an ileal conduit placement.
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
When reviewing the information, which statement should the nurse recognize as needing a
xz xz xz xz xz xz xz xz xz xz xz xz
dditional education? - ans-Empty the pouch when it is half full. xz xz xz xz xz xz xz xz xz xz
A 12 week gestation is admitted to the antepartum unit with a dx of hyperemesis gravidaru
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
m. Which action is most important for the nurse to implement? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz
initiate prescribed IV fluids xz xz xz
A pt with dyspnea is being admitted to the medical unit. To best prepare for the pt arrival, the
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
nurse should ensure that the pt bed is in which position? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
Picture with the bed sitting up xz xz xz xz xz
A pt who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse nu
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
merous questions about the procedure. In preparing the pt for the procedure, which interve
xz xz xz xz xz xz xz xz xz xz xz xz xz
ntion has the highest priority? - ans-Instruct pt to write down questions
xz xz xz xz xz xz xz xz xz xz xz
While caring for a pt post operative dressing, the nurse observes purulent drainage at the w
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ound. Before reporting this finding to the provider, the nurse should review which of the pt la
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
b values? - ans-culture for sensitive organisms
xz xz xz xz xz xz
A pt with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg P
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
O every 12hrs. When the client requests an afternoon snack, which dietary choice should th
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e nurse provide? - ans-Cinnamon apple sauce
xz xz xz xz xz xz
An older male reporting abd pain is admitted from a facility. It has been 7 days since his last
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
BM and his abd is distended, and he just vomited 150ml of dark brown emesis. In what orde
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
r should the nurse implement these interventions? - ans-Send emesis to lab
xz xz xz xz xz xz xz xz xz xz xz
Elevate HOB xz
complete focused assessment xz xz
offers PRN pain meds xz xz xz
,A patient who recently received a prescription for ramelteon to treat sleep deprivation repor
xz xz xz xz xz xz xz xz xz xz xz xz xz
ts experiencing several side effects since taking the med. Which side effect should the nurs
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e report to the healthcare provider? - ans-Somnambulism
xz xz xz xz xz xz xz
A pt is scheduled for a spiral CT scan with contrast to evaluate for pulmonary embolism. Wh
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ich information in the client's history requires follow up by the nurse? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
take metformin for type 2 diabetes xz xz xz xz xz
The nurse should withhold which medication if the client's serum potassium level is 6.2 mE
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
q/? - ans-Spironolactone xz xz
A nurse receives a report on a pt who is four hours post-
xz xz xz xz xz xz xz xz xz xz xz xz
total abdominal hysterectomy. The previous nurse reports that it was necessary to change t
xz xz xz xz xz xz xz xz xz xz xz xz xz
he client's perineal pad hourly and that it is again saturated. The previous nurse also report
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
s that the client's urinary output has decreased. Which action should the nurse implement fi
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
rst? - ans-Assess for weakness or dizziness
xz xz xz xz xz xz
A pt who is admitted for primary hypothyroidism has early signs of myxedema coma. In ass
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
essing the pt, in which sequence should the nurse complete these actions? - ans--
xz xz xz xz xz xz xz xz xz xz xz xz xz
Observe breathing patterns xz xz
-assess blood pressure xz xz
-measure body temp xz xz
-palpate for pedal edema xz xz xz
The nurse is taking the blood pressure measurement of a client with Parkinson's disease.
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Which information in the admission assessment is relevant to the nurse's plan for taking the
xz xz xz xz xz xz xz xz xz xz xz xz xz xz x
blood pressure reading? SATA - ans-Blurred Vision
z xz xz xz xz xz xz
Flat Affect xz
frequent syncope xz
After administering a proton pump inhibitor, which action should the nurse take to evaluate t
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
he effectiveness of the medication? - ans-Ask the pt about gastrointestinal pain
xz xz xz xz xz xz xz xz xz xz xz
A pt is receiving enoxaparin 30 mg subcutaneously twice a day. In assessing for adverse eff
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ects of the medication, which serum laboratory value most important for the nurse to monito
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
r - ans-platelet count
xz xz xz
A pediatric client is taking the beta-
xz xz xz xz xz xz
adrenergic blocking agent propranolol. In developing a teaching plan, the nurse should teaxz xz xz xz xz xz xz xz xz xz xz xz
ch the parents to report which sign of overdose? - ans-Bradycardia
xz xz xz xz xz xz xz xz xz xz
The nurse is demonstrating correct transfer procedures to the unlicensed assistive person
xz xz xz xz xz xz xz xz xz xz xz
nel working on a rehab unit. The UAP asks the nurse how to safely move a physically disabl
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ed pt from the... wheelchair to the bed. Which action should the nurse recommend? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Place the pt locked wheelchair on the pt strong side next to the bed
xz xz xz xz xz xz xz xz xz xz xz xz xz
, The nurse has completed the diet teaching of a client who is being discharged following tx o
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
f a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch ch
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
oice by the pt indicates that the teaching was effective? - ans-
xz xz xz xz xz xz xz xz xz xz xz
A tuna fish sandwich with chips and ice cream
xz xz xz xz xz xz xz xz
When conducting diet teaching for a pt who was dx with a myocardial infarction, which snac
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
k foods should the nurse encourage the pt to eat? SATA - ans-
xz xz xz xz xz xz xz xz xz xz xz xz
Fresh Turkey slices and berries xz xz xz xz
chick bouillon soup and toast xz xz xz xz
raw unsalted almonds and apples xz xz xz xz
A pt taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
implement first? - ans-Observe the appearance of the stool xz xz xz xz xz xz xz xz
A pt is dx with Meniere's disease. Which problem should the nurse identify as most importa
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
nt in the plan of care? - ans-Risk for injury related to vertigo
xz xz xz xz xz xz xz xz xz xz xz xz
A new nurse preparing to irrigate an IV catheter is attaching a 24 gauge needle. Which actio
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
n should the charge nurse implement? - ans-Suggest the nurse use 20g needle
xz xz xz xz xz xz xz xz xz xz xz xz
A nurse working on an Endocrine Unit should see which client first? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
A pt taking corticosteroids who has become disoriented in the last two hours.
xz xz xz xz xz xz xz xz xz xz xz xz
After an older pt receives tx for drug toxicity the healthcare provider prescribes a 24 hr creati
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
nine clearance, the nurse notes that the pt serum creatinine is 0.3mg. Which action should t
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
he nurse implement? - ans-Notify the healthcare provider of the results
xz xz xz xz xz xz xz xz xz xz
An older adult pt with Systemic inflammatory syndrome (SIRS) has a temp of 101.8, HR of 1
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
10, and RR of 24 breaths/ xz xz xz xz xz
min. Which additional finding is most important to report to the healthcare provider? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Serum Creatinine of 2mg/dl xz xz xz
A pt in the third trimester of pregnancy reports that she feels some lumpy places in her brea
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
sts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
healthcare provider in two weeks. What actions should the nurse take? - ans- xz xz xz xz xz xz xz xz xz xz xz xz
Explain that this is normal recreation and can be assessed at the next visit.
xz xz xz xz xz xz xz xz xz xz xz xz xz
A pt presents to the labor and delivery unit with a report of leaking fluid that is greenish-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
brown vaginal discharge. Which action should the nurse take first? - ans-
xz xz xz xz xz xz xz xz xz xz xz
begin continuous fetal monitoring xz xz xz
The mother of a 2 day old infant girl expresses concern about a flea bite type rash on her da
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the
xz xz xz xz xz xz xz xz xz xz xz xz xz
thorax, back, buttocks, and abdomen. Which explanation should the nurse offer? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
This is a common newborn rash that will resolve after several days.
xz xz xz xz xz xz xz xz xz xz xz
QUESTIONS WITH ANSWERS
The nurse is wearing personal protective equipment while caring for a pt. When exiting the r
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
oom, which PPE should be removed first? - ans-Gloves
xz xz xz xz xz xz xz xz
An older pt is brought to the ED with a sudden onset of confusion that occurred after experie
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ncing a fall at home. The daughter, who has power of attorney, has brought the client's pres
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
criptions. Which information should the nurse provide first when reporting to the healthcare
xz xz xz xz xz xz xz xz xz xz xz xz xz
provider using SBAR communication? - ans-Increasing confusion of the pt.
xz xz xz xz xz xz xz xz xz
A pt presses the call bell and requests pain medication for a severe headache. To assess th
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e quality of the pt. Pain, which approach should the nurse use? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
Ask the patient to describe the pain
xz xz xz xz xz xz
A pt tells the nurse about working out with a personal trainer and swimming three times a we
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ek in an effort to lose weight and sleep better. The pt states that it still is taking hours to fall a
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
sleep at night. Which action should the nurse implement? - ans-
xz xz xz xz xz xz xz xz xz xz
Ask the pt for a description of the exercise schedule that is being followed
xz xz xz xz xz xz xz xz xz xz xz xz xz
2 days prior to discharge from the rehab facility, the nurse is teaching a pt who is recovering
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
from Guillain- xz
Barre syndrome about home. Which actions should the nurse include when providing disch
xz xz xz xz xz xz xz xz xz xz xz xz
arge teaching to the pt and spouse? SATA - ans--review safe transfer strategies
xz xz xz xz xz xz xz xz xz xz xz xz
-develop a nutritional plan xz xz xz
-help identify community support
xz xz xz
The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clin
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ic. Which outcome indicates that the program was effective? - ans-
xz xz xz xz xz xz xz xz xz xz
pt who develop disease complications promptly received rehabilitation
xz xz xz xz xz xz xz
The nurse has received funding to design a health promotion project for African American w
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
omen who are at risk for developing breast cancer. Which resource is most important in des
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
igning this program? - ans-participation of community leaders in planning the program
xz xz xz xz xz xz xz xz xz xz xz
A pt with multiple injuries is being treated in the burn trauma unit just hours after the injuries
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
occurred. The healthcare provider instructs the nurse to avoid auto contamination when pe
xz xz xz xz xz xz xz xz xz xz xz xz
rforming dressing changes. Which intervention is most important for the nurse to implemen
xz xz xz xz xz xz xz xz xz xz xz xz
t? - ans-use gown, mask, and gloves with dressing changes
xz xz xz xz xz xz xz xz xz
A pt is recovering in the critical care unit following a cardiac cath. IV nitro and heparin are inf
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
using. The pt is sedated but responds to instructions. After changing positions, the pt compl
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
,ains of pain at the right groin insertion site. What action should the nurse implement? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Stimulate the pt to take deep breaths xz xz xz xz xz xz
Prior to obtaining a trapeze bar for a pt with limited mobility, which pt assessment is most im
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
portant for the nurse to obtain? - ans-upper body muscle strength
xz xz xz xz xz xz xz xz xz xz
While the nurse is assessing an older pt fall risk, the pt reports living at home alone and nev
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
er falling. Which action should the nurse take? - ans-
xz xz xz xz xz xz xz xz xz
Continue to obtain pt data needed to complete the fall risk survey xz xz xz xz xz xz xz xz xz xz xz
The nurse is feeding an older adult who was admitted with aspiration pneumonia. The pt is
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
weak and begins coughing while attempting to drink through a straw. Which intervention sh
xz xz xz xz xz xz xz xz xz xz xz xz xz
ould the nurse implement? - ans-Teach coughing and deep breathing exercises
xz xz xz xz xz xz xz xz xz xz
The nurse is teaching the pt about home care after surgery for an ileal conduit placement.
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
When reviewing the information, which statement should the nurse recognize as needing a
xz xz xz xz xz xz xz xz xz xz xz xz
dditional education? - ans-Empty the pouch when it is half full. xz xz xz xz xz xz xz xz xz xz
A 12 week gestation is admitted to the antepartum unit with a dx of hyperemesis gravidaru
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
m. Which action is most important for the nurse to implement? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz
initiate prescribed IV fluids xz xz xz
A pt with dyspnea is being admitted to the medical unit. To best prepare for the pt arrival, the
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
nurse should ensure that the pt bed is in which position? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
Picture with the bed sitting up xz xz xz xz xz
A pt who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse nu
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
merous questions about the procedure. In preparing the pt for the procedure, which interve
xz xz xz xz xz xz xz xz xz xz xz xz xz
ntion has the highest priority? - ans-Instruct pt to write down questions
xz xz xz xz xz xz xz xz xz xz xz
While caring for a pt post operative dressing, the nurse observes purulent drainage at the w
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ound. Before reporting this finding to the provider, the nurse should review which of the pt la
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
b values? - ans-culture for sensitive organisms
xz xz xz xz xz xz
A pt with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg P
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
O every 12hrs. When the client requests an afternoon snack, which dietary choice should th
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e nurse provide? - ans-Cinnamon apple sauce
xz xz xz xz xz xz
An older male reporting abd pain is admitted from a facility. It has been 7 days since his last
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
BM and his abd is distended, and he just vomited 150ml of dark brown emesis. In what orde
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
r should the nurse implement these interventions? - ans-Send emesis to lab
xz xz xz xz xz xz xz xz xz xz xz
Elevate HOB xz
complete focused assessment xz xz
offers PRN pain meds xz xz xz
,A patient who recently received a prescription for ramelteon to treat sleep deprivation repor
xz xz xz xz xz xz xz xz xz xz xz xz xz
ts experiencing several side effects since taking the med. Which side effect should the nurs
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e report to the healthcare provider? - ans-Somnambulism
xz xz xz xz xz xz xz
A pt is scheduled for a spiral CT scan with contrast to evaluate for pulmonary embolism. Wh
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ich information in the client's history requires follow up by the nurse? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
take metformin for type 2 diabetes xz xz xz xz xz
The nurse should withhold which medication if the client's serum potassium level is 6.2 mE
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
q/? - ans-Spironolactone xz xz
A nurse receives a report on a pt who is four hours post-
xz xz xz xz xz xz xz xz xz xz xz xz
total abdominal hysterectomy. The previous nurse reports that it was necessary to change t
xz xz xz xz xz xz xz xz xz xz xz xz xz
he client's perineal pad hourly and that it is again saturated. The previous nurse also report
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
s that the client's urinary output has decreased. Which action should the nurse implement fi
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
rst? - ans-Assess for weakness or dizziness
xz xz xz xz xz xz
A pt who is admitted for primary hypothyroidism has early signs of myxedema coma. In ass
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
essing the pt, in which sequence should the nurse complete these actions? - ans--
xz xz xz xz xz xz xz xz xz xz xz xz xz
Observe breathing patterns xz xz
-assess blood pressure xz xz
-measure body temp xz xz
-palpate for pedal edema xz xz xz
The nurse is taking the blood pressure measurement of a client with Parkinson's disease.
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Which information in the admission assessment is relevant to the nurse's plan for taking the
xz xz xz xz xz xz xz xz xz xz xz xz xz xz x
blood pressure reading? SATA - ans-Blurred Vision
z xz xz xz xz xz xz
Flat Affect xz
frequent syncope xz
After administering a proton pump inhibitor, which action should the nurse take to evaluate t
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
he effectiveness of the medication? - ans-Ask the pt about gastrointestinal pain
xz xz xz xz xz xz xz xz xz xz xz
A pt is receiving enoxaparin 30 mg subcutaneously twice a day. In assessing for adverse eff
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ects of the medication, which serum laboratory value most important for the nurse to monito
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
r - ans-platelet count
xz xz xz
A pediatric client is taking the beta-
xz xz xz xz xz xz
adrenergic blocking agent propranolol. In developing a teaching plan, the nurse should teaxz xz xz xz xz xz xz xz xz xz xz xz
ch the parents to report which sign of overdose? - ans-Bradycardia
xz xz xz xz xz xz xz xz xz xz
The nurse is demonstrating correct transfer procedures to the unlicensed assistive person
xz xz xz xz xz xz xz xz xz xz xz
nel working on a rehab unit. The UAP asks the nurse how to safely move a physically disabl
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ed pt from the... wheelchair to the bed. Which action should the nurse recommend? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Place the pt locked wheelchair on the pt strong side next to the bed
xz xz xz xz xz xz xz xz xz xz xz xz xz
, The nurse has completed the diet teaching of a client who is being discharged following tx o
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
f a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch ch
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
oice by the pt indicates that the teaching was effective? - ans-
xz xz xz xz xz xz xz xz xz xz xz
A tuna fish sandwich with chips and ice cream
xz xz xz xz xz xz xz xz
When conducting diet teaching for a pt who was dx with a myocardial infarction, which snac
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
k foods should the nurse encourage the pt to eat? SATA - ans-
xz xz xz xz xz xz xz xz xz xz xz xz
Fresh Turkey slices and berries xz xz xz xz
chick bouillon soup and toast xz xz xz xz
raw unsalted almonds and apples xz xz xz xz
A pt taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
implement first? - ans-Observe the appearance of the stool xz xz xz xz xz xz xz xz
A pt is dx with Meniere's disease. Which problem should the nurse identify as most importa
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
nt in the plan of care? - ans-Risk for injury related to vertigo
xz xz xz xz xz xz xz xz xz xz xz xz
A new nurse preparing to irrigate an IV catheter is attaching a 24 gauge needle. Which actio
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
n should the charge nurse implement? - ans-Suggest the nurse use 20g needle
xz xz xz xz xz xz xz xz xz xz xz xz
A nurse working on an Endocrine Unit should see which client first? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
A pt taking corticosteroids who has become disoriented in the last two hours.
xz xz xz xz xz xz xz xz xz xz xz xz
After an older pt receives tx for drug toxicity the healthcare provider prescribes a 24 hr creati
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
nine clearance, the nurse notes that the pt serum creatinine is 0.3mg. Which action should t
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
he nurse implement? - ans-Notify the healthcare provider of the results
xz xz xz xz xz xz xz xz xz xz
An older adult pt with Systemic inflammatory syndrome (SIRS) has a temp of 101.8, HR of 1
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
10, and RR of 24 breaths/ xz xz xz xz xz
min. Which additional finding is most important to report to the healthcare provider? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Serum Creatinine of 2mg/dl xz xz xz
A pt in the third trimester of pregnancy reports that she feels some lumpy places in her brea
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
sts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
healthcare provider in two weeks. What actions should the nurse take? - ans- xz xz xz xz xz xz xz xz xz xz xz xz
Explain that this is normal recreation and can be assessed at the next visit.
xz xz xz xz xz xz xz xz xz xz xz xz xz
A pt presents to the labor and delivery unit with a report of leaking fluid that is greenish-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
brown vaginal discharge. Which action should the nurse take first? - ans-
xz xz xz xz xz xz xz xz xz xz xz
begin continuous fetal monitoring xz xz xz
The mother of a 2 day old infant girl expresses concern about a flea bite type rash on her da
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the
xz xz xz xz xz xz xz xz xz xz xz xz xz
thorax, back, buttocks, and abdomen. Which explanation should the nurse offer? - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
This is a common newborn rash that will resolve after several days.
xz xz xz xz xz xz xz xz xz xz xz
