EXIT HESI -PN EXAM A PRACTICE
QUESTIONS EXAM 2026 LATEST
UPDATE WITH VERIFIED QUESTIONS
AND CORRECT DETAILED ANSWERS
A nurse who has recently completed orientation is beginning work in the labor and del
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ivery unit for the first time. When making assignments, which client should the charge
ib ib ib ib ib ib ib ib ib ib ib ib ib i
bnurse assign to this new nurse?ib ib ib ib ib
A.A primigravida who is 8 cm dilated after 14 hours of labor
ib ib ib ib ib ib ib ib ib ib ib
B.A client scheduled for a repeat cesarean birth at 38 weeks' gestation
ib ib ib ib ib ib ib ib ib ib ib ib
C.A client being induced for fetal demise at 20 weeks' gestation
ib ib ib ib ib ib ib ib ib ib ib
D.A multiparous client who is dilated 5 cm and 50% effaced - ANSWERS-D
ib ib ib ib ib ib ib ib ib ib ib ib ib
The new nurse should be assigned the least complicated client to gain experience an
ib ib ib ib ib ib ib ib ib ib ib ib ib
d confidence, as well as protect client safety. Of the clients available for assignment, (
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
D) is progressing well and is the least complicated. (A, B and C) have actual or potent
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ial complications and should be assigned to a more experienced nurse.
ib ib ib ib ib ib ib ib ib ib
A client with human immunodeficiency virus (HIV) infection has white lesions in the or
ib ib ib ib ib ib ib ib ib ib ib ib ib
al cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as
ib ib ib ib ib ib ib ib ib ib ib ib
a swish and swallow. Which information is most important for the nurse to provide the
ib ib ib ib ib ib ib ib ib ib ib ib ib ib i
client?
b
A.Oral hygiene should be performed before the medication. B.Antifungal medications
ib ib ib ib ib ib ib ib ib i
bare available in tablet, suppository, and liquid forms.
ib ib ib ib ib ib ib
C.Candida albicans is the organism that causes the white lesions in the mouth.
ib ib ib ib ib ib ib ib ib ib ib ib ib
D.The dietary intake of dairy and spicy foods should be limited. - ANSWERS-A
ib ib ib ib ib ib ib ib ib ib ib ib ib
HIV infection causes depression of cell-
ib ib ib ib ib
mediated immunity that allows an overgrowth of Candida albicans (oral moniliasis), w
ib ib ib ib ib ib ib ib ib ib ib
hich appears as white, cheesy plaque or lesions that resemble milk curds. To ensure
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
effective contact of the medication with the oral lesions, oral liquids should be consu
ib ib ib ib ib ib ib ib ib ib ib ib ib
med and oral hygiene performed before swishing the liquid Mycostatin (A). (B and C)
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
provide the client with additional information about the pathogenesis and treatment of
ib ib ib ib ib ib ib ib ib ib ib i
bopportunistic infections, but (A) allows the client to participate in self- ib ib ib ib ib ib ib ib ib ib
care of the oral infection. Dietary restriction of spicy foods reduces discomfort associa
ib ib ib ib ib ib ib ib ib ib ib ib
ted with stomatitis, but restriction of dairy products is not indicated (D).
ib ib ib ib ib ib ib ib ib ib ib
A client who is admitted with emphysema is having difficulty breathing. In which positi
ib ib ib ib ib ib ib ib ib ib ib ib ib
on should the nurse place the client?
ib ib ib ib ib ib
A.High Fowler's position without a pillow behind the head
ib ib ib ib ib ib ib ib
B.Semi-Fowler's position with a single pillow behind the head
ib ib ib ib ib ib ib ib ib
C.Right side-lying position with the head of the bed elevated 45 degrees
ib ib ib ib ib ib ib ib ib ib ib ib
, D.Sitting upright and forward with both arms supported on an over the bed table -
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ANSWERS-D
ib
Adequate lung expansion is dependent on deep breaths that allow the respiratory mu
ib ib ib ib ib ib ib ib ib ib ib ib
scles to increase the longitudinal and anterior-
ib ib ib ib ib ib
posterior size of the thoracic cage. Sitting upright and leaning forward with the arms s
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
upported on an over the bed table (D) allows the thoracic cage to expand in all four di
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
rections and reduces dyspnea. A high Fowler's position does not allow maximum exp
ib ib ib ib ib ib ib ib ib ib ib ib
ansion of the posterior lobes of the lungs (A). A semi-
ib ib ib ib ib ib ib ib ib ib
Fowler's position restricts expansion of the anterior-
ib ib ib ib ib ib
posterior diameter of the thoracic cage (B). Positioning a client on the right side with t
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
he head of the bed elevated (C) does not facilitate lung expansion.
ib ib ib ib ib ib ib ib ib ib ib
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (
ib ib ib ib ib ib ib ib ib ib ib ib ib
HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, t
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
he client's serum potassium level is 4 mEq/L. What is the most likely cause of this clie
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
nt's potassium level?
ib ib
A.The client is noncompliant with his medications.
ib ib ib ib ib ib
B.The client recently consumed large quantities of pears or nuts.
ib ib ib ib ib ib ib ib ib ib
C.The client's renal function has affected his potassium level.
ib ib ib ib ib ib ib ib ib
D.The client needs to be started on a potassium supplement. - ANSWERS-C
ib ib ib ib ib ib ib ib ib ib ib ib
The client has a normalized potassium level despite diuretic use (C). The kidney auto
ib ib ib ib ib ib ib ib ib ib ib ib ib
matically secretes 90% of potassium consumed, but in chronic renal insufficiency (C
ib ib ib ib ib ib ib ib ib ib ib
RI), less potassium is excreted than normal. Therefore, the two potassium-
ib ib ib ib ib ib ib ib ib ib
wasting drugs, a thiazide diuretic and loop diuretic, are not likely to affect potassium l
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
evels. The normal potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
mEq/L, there is no reason to believe that the client is noncompliant with his treatment
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
(A). Pears and nuts do not affect the serum potassium level (B). There is no need for
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
a potassium supplement (D) because the client's potassium level is within the normal
ib ib ib ib ib ib ib ib ib ib ib ib ib
range.
A registered nurse (RN) delivers telehealth services to clients via electronic communi
ib ib ib ib ib ib ib ib ib ib ib
cation. Which nursing action creates the greatest risk for professional liability and has
ib ib ib ib ib ib ib ib ib ib ib ib i
the potential for a malpractice lawsuit?
b ib ib ib ib ib
A.Participating in telephone consultations with clients ib ib ib ib ib
B.Identifying oneself by name and title to clients in telehealth communications
ib ib ib ib ib ib ib ib ib ib ib
C.Sending medical records to health care providers via the Internet
ib ib ib ib ib ib ib ib ib ib
D.Answering a client-initiated health question via electronic mail - ANSWERS-C
ib ib ib ib ib ib ib ib ib ib
Sending medical records over the Internet, even with the latest security protection, cr
ib ib ib ib ib ib ib ib ib ib ib ib
eates the greatest risk for liability because of the high potential of breaching client co
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
nfidentiality and the amount of information being transferred (C). Client confidentiality
ib ib ib ib ib ib ib ib ib ib ib
is protected by federal wiretapping laws making telephone consultation (A) a private
ib ib ib ib ib ib ib ib ib ib ib ib
and protected form of communication. By stating one's name and credentials in teleh
ib ib ib ib ib ib ib ib ib ib ib ib
ealth communication (B), one is taking responsibility for the encounter. E-
ib ib ib ib ib ib ib ib ib ib
mail initiated by the client (D) poses less risk than sending records via the Internet.
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
Which pathophysiologic response supports the contraindication for opioids, such as
ib ib ib ib ib ib ib ib ib ib
morphine, in clients with increased intracranial pressure (ICP)?
ib ib ib ib ib ib ib
,A.Sedation produced by opioids is a result of a prolonged half- ib ib ib ib ib ib ib ib ib ib
life when the ICP is elevated.
ib ib ib ib ib
B.Higher doses of opioids are required when cerebral blood flow is reduced by an el
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
evated ICP. ib
C.Dysphoria from opioids contributes to altered levels of consciousness with an elev
ib ib ib ib ib ib ib ib ib ib ib ib
ated ICP. ib
D.Opioids suppress respirations, which increases Pco2 and contributes to an elevate
ib ib ib ib ib ib ib ib ib ib
d ICP. - ANSWERS-D
ib ib ib
The greatest risk associated with opioids such as morphine (D) is respiratory depress
ib ib ib ib ib ib ib ib ib ib ib ib
ion that causes an increase in Pco2, which increases ICP and masks the early signs
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
of intracranial bleeding in head injury. (A, B, and C) do not support the risks associate
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
d with opioid use in a client with increased ICP.
ib ib ib ib ib ib ib ib ib
The charge nurse of a medical surgical unit is alerted to an impending disaster requiri
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ng implementation of the hospital's disaster plan. Specific facts about the nature of thi
ib ib ib ib ib ib ib ib ib ib ib ib ib
s disaster are not yet known. Which instruction should the charge nurse give to the ot
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
her staff members at this time?
ib ib ib ib ib
A.Prepare to evacuate the unit, starting with the bedridden clients.
ib ib ib ib ib ib ib ib ib
B.UAPs should report to the emergency center to handle transports.
ib ib ib ib ib ib ib ib ib ib
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
ib ib ib ib ib ib ib ib ib ib ib ib ib
D.Continue with current assignments until more instructions are received. -
ib ib ib ib ib ib ib ib ib ib
ANSWERS-D
ib
When faced with an impending disaster, hospital personnel may be alerted but shoul
ib ib ib ib ib ib ib ib ib ib ib ib
d continue with current client care assignments until further instructions are received (
ib ib ib ib ib ib ib ib ib ib ib ib
D). Evacuation is typically a response of last resort that begins with clients who are m
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ost able to ambulate (A). (B) is premature and is likely to increase the chaos if incomi
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ng casualties are anticipated. (C) is poor utilization of personnel.
ib ib ib ib ib ib ib ib ib
The nurse assesses a client while the UAP measures the client's vital signs. The clie
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
nt's vital signs change suddenly, and the nurse determines that the client's condition i
ib ib ib ib ib ib ib ib ib ib ib ib ib
s worsening. The nurse is unsure of the client's resuscitative status and needs to che
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ck the client's medical record for any advanced directives. Which action should the nu
ib ib ib ib ib ib ib ib ib ib ib ib ib
rse implement? ib
A.Ask the UAP to check for the advanced directive while the nurse completes the ass
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
essment.
B.Assign the UAP to complete the assessment while the nurse checks for the advanc
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ed directive. ib
C.Check the medical record for the advanced directive and then complete the client a
ib ib ib ib ib ib ib ib ib ib ib ib ib
ssessment.
D.Call for the charge nurse to check the advanced directive while continuing to asse
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ss the client. - ANSWERS-D
ib ib ib ib
Because the client's condition is worsening, the nurse should remain with the client a
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nd continue the assessment while calling for help from the charge nurse to determine
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the client's resuscitative status (D). (A and B) are tasks that must be completed by a
b ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
nurse and cannot be delegated to the UAP. (C) is contraindicated.
ib ib ib ib ib ib ib ib ib ib
The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the
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nurse. Which task is important for the nurse to perform, rather than the UAP?
b ib ib ib ib ib ib ib ib ib ib ib ib ib
, A.Remove the client's nail polish and dentures. ib ib ib ib ib ib
B.Assist the client to the restroom to void.
ib ib ib ib ib ib ib ib
C.Obtain the client's height and weight.
ib ib ib ib ib ib
D.Offer the client emotional support. - ANSWERS-D
ib ib ib ib ib ib ib
By using therapeutic techniques to offer support (D), the nurse can determine any cli
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ent concerns that need to be addressed. (A, B, and C) are all actions that can be perf
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ormed by the UAP under the supervision of the nurse.
ib ib ib ib ib ib ib ib ib
Until the census on the obstetrics (OB) unit increases, an unlicensed assistive person
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nel (UAP) who usually works in labor and delivery and the newborn nursery is assign
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ed to work on the postoperative unit. Which client would be best for the charge nurse
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
to assign to this UAP?
ib ib ib ib
A.An adolescent who was readmitted to the hospital because of a postoperative infe
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ction
B.A woman with a new colostomy who requires discharge teaching
ib ib ib ib ib ib ib ib ib ib
C.A woman who had a hip replacement and may be transferred to the home care uni
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
t
D.A man who had a cholecystectomy and currently has a nasogastric tube set to inte
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rmittent suction - ANSWERS-C ib ib ib
The charge nurse will be responsible for providing a report to the home care unit if th
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e transfer occurs (A). The client is infected and an employee who works on an OB uni
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
t should be assigned to clean cases in case the employee is required to return to the
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
OB unit (B). This requires the skills of a registered nurse (RN) to do discharge teachin
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
g and provide emotional support (D). This may require skills beyond the level of this
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
UAP.
A male client is admitted for observation after being hit on the head with a baseball b
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
at. Six hours after admission, the client attempts to crawl out of bed and asks the nur
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
se why there are so many bugs in his bed. His vital signs are stable, and the pulse oxi
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
meter reading is 98% on room air. Which intervention should the nurse perform first?
ib ib ib ib ib ib ib ib ib ib ib ib ib
A.Administer oxygen per nasal cannula at 2 L/min. ib ib ib ib ib ib ib
B.Plan to check his vital signs again in 30 minutes.
ib ib ib ib ib ib ib ib ib
C.Notify the health care provider of the change in mental status.
ib ib ib ib ib ib ib ib ib ib
D.Ask the client why he thinks there are bugs in the bed. - ANSWERS-C
ib ib ib ib ib ib ib ib ib ib ib ib ib
One of the earliest signs of increased intracranial pressure (ICP) is a change in ment
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
al status (C). It is important to act early and quickly when symptoms of increased ICP
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
occur. Because his oxygen saturation is normal, the administration of oxygen (A) is n
ib ib ib ib ib ib ib ib ib ib ib ib ib
ot the top priority. Vital signs should be monitored frequently (B), but the client's confu
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
sion should be reported immediately. (D) is not a useful intervention.
ib ib ib ib ib ib ib ib ib ib
The nurse is monitoring a client who is receiving bedside conscious sedation with mid
ib ib ib ib ib ib ib ib ib ib ib ib ib
azolam hydrochloride (Versed). In assessing the client, the nurse determines that the
ib ib ib ib ib ib ib ib ib ib ib i
client has slurred speech with diplopia. Based on this finding, what action should the
b ib ib ib ib ib ib ib ib ib ib ib ib ib ib
nurse take? ib
ib A.Open the airway with a chin lift-head tilt maneuver. ib ib ib ib ib ib ib ib
ib B.Obtain a fingerstick glucose reading. ib ib ib ib
QUESTIONS EXAM 2026 LATEST
UPDATE WITH VERIFIED QUESTIONS
AND CORRECT DETAILED ANSWERS
A nurse who has recently completed orientation is beginning work in the labor and del
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ivery unit for the first time. When making assignments, which client should the charge
ib ib ib ib ib ib ib ib ib ib ib ib ib i
bnurse assign to this new nurse?ib ib ib ib ib
A.A primigravida who is 8 cm dilated after 14 hours of labor
ib ib ib ib ib ib ib ib ib ib ib
B.A client scheduled for a repeat cesarean birth at 38 weeks' gestation
ib ib ib ib ib ib ib ib ib ib ib ib
C.A client being induced for fetal demise at 20 weeks' gestation
ib ib ib ib ib ib ib ib ib ib ib
D.A multiparous client who is dilated 5 cm and 50% effaced - ANSWERS-D
ib ib ib ib ib ib ib ib ib ib ib ib ib
The new nurse should be assigned the least complicated client to gain experience an
ib ib ib ib ib ib ib ib ib ib ib ib ib
d confidence, as well as protect client safety. Of the clients available for assignment, (
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
D) is progressing well and is the least complicated. (A, B and C) have actual or potent
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ial complications and should be assigned to a more experienced nurse.
ib ib ib ib ib ib ib ib ib ib
A client with human immunodeficiency virus (HIV) infection has white lesions in the or
ib ib ib ib ib ib ib ib ib ib ib ib ib
al cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as
ib ib ib ib ib ib ib ib ib ib ib ib
a swish and swallow. Which information is most important for the nurse to provide the
ib ib ib ib ib ib ib ib ib ib ib ib ib ib i
client?
b
A.Oral hygiene should be performed before the medication. B.Antifungal medications
ib ib ib ib ib ib ib ib ib i
bare available in tablet, suppository, and liquid forms.
ib ib ib ib ib ib ib
C.Candida albicans is the organism that causes the white lesions in the mouth.
ib ib ib ib ib ib ib ib ib ib ib ib ib
D.The dietary intake of dairy and spicy foods should be limited. - ANSWERS-A
ib ib ib ib ib ib ib ib ib ib ib ib ib
HIV infection causes depression of cell-
ib ib ib ib ib
mediated immunity that allows an overgrowth of Candida albicans (oral moniliasis), w
ib ib ib ib ib ib ib ib ib ib ib
hich appears as white, cheesy plaque or lesions that resemble milk curds. To ensure
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
effective contact of the medication with the oral lesions, oral liquids should be consu
ib ib ib ib ib ib ib ib ib ib ib ib ib
med and oral hygiene performed before swishing the liquid Mycostatin (A). (B and C)
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
provide the client with additional information about the pathogenesis and treatment of
ib ib ib ib ib ib ib ib ib ib ib i
bopportunistic infections, but (A) allows the client to participate in self- ib ib ib ib ib ib ib ib ib ib
care of the oral infection. Dietary restriction of spicy foods reduces discomfort associa
ib ib ib ib ib ib ib ib ib ib ib ib
ted with stomatitis, but restriction of dairy products is not indicated (D).
ib ib ib ib ib ib ib ib ib ib ib
A client who is admitted with emphysema is having difficulty breathing. In which positi
ib ib ib ib ib ib ib ib ib ib ib ib ib
on should the nurse place the client?
ib ib ib ib ib ib
A.High Fowler's position without a pillow behind the head
ib ib ib ib ib ib ib ib
B.Semi-Fowler's position with a single pillow behind the head
ib ib ib ib ib ib ib ib ib
C.Right side-lying position with the head of the bed elevated 45 degrees
ib ib ib ib ib ib ib ib ib ib ib ib
, D.Sitting upright and forward with both arms supported on an over the bed table -
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ANSWERS-D
ib
Adequate lung expansion is dependent on deep breaths that allow the respiratory mu
ib ib ib ib ib ib ib ib ib ib ib ib
scles to increase the longitudinal and anterior-
ib ib ib ib ib ib
posterior size of the thoracic cage. Sitting upright and leaning forward with the arms s
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
upported on an over the bed table (D) allows the thoracic cage to expand in all four di
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
rections and reduces dyspnea. A high Fowler's position does not allow maximum exp
ib ib ib ib ib ib ib ib ib ib ib ib
ansion of the posterior lobes of the lungs (A). A semi-
ib ib ib ib ib ib ib ib ib ib
Fowler's position restricts expansion of the anterior-
ib ib ib ib ib ib
posterior diameter of the thoracic cage (B). Positioning a client on the right side with t
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
he head of the bed elevated (C) does not facilitate lung expansion.
ib ib ib ib ib ib ib ib ib ib ib
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (
ib ib ib ib ib ib ib ib ib ib ib ib ib
HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, t
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
he client's serum potassium level is 4 mEq/L. What is the most likely cause of this clie
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
nt's potassium level?
ib ib
A.The client is noncompliant with his medications.
ib ib ib ib ib ib
B.The client recently consumed large quantities of pears or nuts.
ib ib ib ib ib ib ib ib ib ib
C.The client's renal function has affected his potassium level.
ib ib ib ib ib ib ib ib ib
D.The client needs to be started on a potassium supplement. - ANSWERS-C
ib ib ib ib ib ib ib ib ib ib ib ib
The client has a normalized potassium level despite diuretic use (C). The kidney auto
ib ib ib ib ib ib ib ib ib ib ib ib ib
matically secretes 90% of potassium consumed, but in chronic renal insufficiency (C
ib ib ib ib ib ib ib ib ib ib ib
RI), less potassium is excreted than normal. Therefore, the two potassium-
ib ib ib ib ib ib ib ib ib ib
wasting drugs, a thiazide diuretic and loop diuretic, are not likely to affect potassium l
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
evels. The normal potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
mEq/L, there is no reason to believe that the client is noncompliant with his treatment
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
(A). Pears and nuts do not affect the serum potassium level (B). There is no need for
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
a potassium supplement (D) because the client's potassium level is within the normal
ib ib ib ib ib ib ib ib ib ib ib ib ib
range.
A registered nurse (RN) delivers telehealth services to clients via electronic communi
ib ib ib ib ib ib ib ib ib ib ib
cation. Which nursing action creates the greatest risk for professional liability and has
ib ib ib ib ib ib ib ib ib ib ib ib i
the potential for a malpractice lawsuit?
b ib ib ib ib ib
A.Participating in telephone consultations with clients ib ib ib ib ib
B.Identifying oneself by name and title to clients in telehealth communications
ib ib ib ib ib ib ib ib ib ib ib
C.Sending medical records to health care providers via the Internet
ib ib ib ib ib ib ib ib ib ib
D.Answering a client-initiated health question via electronic mail - ANSWERS-C
ib ib ib ib ib ib ib ib ib ib
Sending medical records over the Internet, even with the latest security protection, cr
ib ib ib ib ib ib ib ib ib ib ib ib
eates the greatest risk for liability because of the high potential of breaching client co
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
nfidentiality and the amount of information being transferred (C). Client confidentiality
ib ib ib ib ib ib ib ib ib ib ib
is protected by federal wiretapping laws making telephone consultation (A) a private
ib ib ib ib ib ib ib ib ib ib ib ib
and protected form of communication. By stating one's name and credentials in teleh
ib ib ib ib ib ib ib ib ib ib ib ib
ealth communication (B), one is taking responsibility for the encounter. E-
ib ib ib ib ib ib ib ib ib ib
mail initiated by the client (D) poses less risk than sending records via the Internet.
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
Which pathophysiologic response supports the contraindication for opioids, such as
ib ib ib ib ib ib ib ib ib ib
morphine, in clients with increased intracranial pressure (ICP)?
ib ib ib ib ib ib ib
,A.Sedation produced by opioids is a result of a prolonged half- ib ib ib ib ib ib ib ib ib ib
life when the ICP is elevated.
ib ib ib ib ib
B.Higher doses of opioids are required when cerebral blood flow is reduced by an el
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
evated ICP. ib
C.Dysphoria from opioids contributes to altered levels of consciousness with an elev
ib ib ib ib ib ib ib ib ib ib ib ib
ated ICP. ib
D.Opioids suppress respirations, which increases Pco2 and contributes to an elevate
ib ib ib ib ib ib ib ib ib ib
d ICP. - ANSWERS-D
ib ib ib
The greatest risk associated with opioids such as morphine (D) is respiratory depress
ib ib ib ib ib ib ib ib ib ib ib ib
ion that causes an increase in Pco2, which increases ICP and masks the early signs
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
of intracranial bleeding in head injury. (A, B, and C) do not support the risks associate
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
d with opioid use in a client with increased ICP.
ib ib ib ib ib ib ib ib ib
The charge nurse of a medical surgical unit is alerted to an impending disaster requiri
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ng implementation of the hospital's disaster plan. Specific facts about the nature of thi
ib ib ib ib ib ib ib ib ib ib ib ib ib
s disaster are not yet known. Which instruction should the charge nurse give to the ot
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
her staff members at this time?
ib ib ib ib ib
A.Prepare to evacuate the unit, starting with the bedridden clients.
ib ib ib ib ib ib ib ib ib
B.UAPs should report to the emergency center to handle transports.
ib ib ib ib ib ib ib ib ib ib
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
ib ib ib ib ib ib ib ib ib ib ib ib ib
D.Continue with current assignments until more instructions are received. -
ib ib ib ib ib ib ib ib ib ib
ANSWERS-D
ib
When faced with an impending disaster, hospital personnel may be alerted but shoul
ib ib ib ib ib ib ib ib ib ib ib ib
d continue with current client care assignments until further instructions are received (
ib ib ib ib ib ib ib ib ib ib ib ib
D). Evacuation is typically a response of last resort that begins with clients who are m
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ost able to ambulate (A). (B) is premature and is likely to increase the chaos if incomi
ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ng casualties are anticipated. (C) is poor utilization of personnel.
ib ib ib ib ib ib ib ib ib
The nurse assesses a client while the UAP measures the client's vital signs. The clie
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
nt's vital signs change suddenly, and the nurse determines that the client's condition i
ib ib ib ib ib ib ib ib ib ib ib ib ib
s worsening. The nurse is unsure of the client's resuscitative status and needs to che
ib ib ib ib ib ib ib ib ib ib ib ib ib ib
ck the client's medical record for any advanced directives. Which action should the nu
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rse implement? ib
A.Ask the UAP to check for the advanced directive while the nurse completes the ass
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essment.
B.Assign the UAP to complete the assessment while the nurse checks for the advanc
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ed directive. ib
C.Check the medical record for the advanced directive and then complete the client a
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ssessment.
D.Call for the charge nurse to check the advanced directive while continuing to asse
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ss the client. - ANSWERS-D
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Because the client's condition is worsening, the nurse should remain with the client a
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nd continue the assessment while calling for help from the charge nurse to determine
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the client's resuscitative status (D). (A and B) are tasks that must be completed by a
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nurse and cannot be delegated to the UAP. (C) is contraindicated.
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The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the
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nurse. Which task is important for the nurse to perform, rather than the UAP?
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, A.Remove the client's nail polish and dentures. ib ib ib ib ib ib
B.Assist the client to the restroom to void.
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C.Obtain the client's height and weight.
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D.Offer the client emotional support. - ANSWERS-D
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By using therapeutic techniques to offer support (D), the nurse can determine any cli
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ent concerns that need to be addressed. (A, B, and C) are all actions that can be perf
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ormed by the UAP under the supervision of the nurse.
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Until the census on the obstetrics (OB) unit increases, an unlicensed assistive person
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nel (UAP) who usually works in labor and delivery and the newborn nursery is assign
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ed to work on the postoperative unit. Which client would be best for the charge nurse
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to assign to this UAP?
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A.An adolescent who was readmitted to the hospital because of a postoperative infe
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ction
B.A woman with a new colostomy who requires discharge teaching
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C.A woman who had a hip replacement and may be transferred to the home care uni
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t
D.A man who had a cholecystectomy and currently has a nasogastric tube set to inte
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rmittent suction - ANSWERS-C ib ib ib
The charge nurse will be responsible for providing a report to the home care unit if th
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e transfer occurs (A). The client is infected and an employee who works on an OB uni
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t should be assigned to clean cases in case the employee is required to return to the
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OB unit (B). This requires the skills of a registered nurse (RN) to do discharge teachin
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g and provide emotional support (D). This may require skills beyond the level of this
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UAP.
A male client is admitted for observation after being hit on the head with a baseball b
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at. Six hours after admission, the client attempts to crawl out of bed and asks the nur
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se why there are so many bugs in his bed. His vital signs are stable, and the pulse oxi
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meter reading is 98% on room air. Which intervention should the nurse perform first?
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A.Administer oxygen per nasal cannula at 2 L/min. ib ib ib ib ib ib ib
B.Plan to check his vital signs again in 30 minutes.
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C.Notify the health care provider of the change in mental status.
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D.Ask the client why he thinks there are bugs in the bed. - ANSWERS-C
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One of the earliest signs of increased intracranial pressure (ICP) is a change in ment
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al status (C). It is important to act early and quickly when symptoms of increased ICP
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occur. Because his oxygen saturation is normal, the administration of oxygen (A) is n
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ot the top priority. Vital signs should be monitored frequently (B), but the client's confu
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sion should be reported immediately. (D) is not a useful intervention.
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The nurse is monitoring a client who is receiving bedside conscious sedation with mid
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azolam hydrochloride (Versed). In assessing the client, the nurse determines that the
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client has slurred speech with diplopia. Based on this finding, what action should the
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nurse take? ib
ib A.Open the airway with a chin lift-head tilt maneuver. ib ib ib ib ib ib ib ib
ib B.Obtain a fingerstick glucose reading. ib ib ib ib
