Hesi comprehensive pn exit exam

1 HESI Comprehensive PN EXIT Exam The nurse is planning care for the a client who hasfourth degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. What intervention has the highest priority? A. Administer Prescribed stoolsoftner B. Administerprescribed PRNsleepmedications. C. Encourage breastfeeding to promote uterine involution D. Encourage use of prescribed analgesicperinealsprays. A. Administer Prescribed stoolsoftner The nurse is palpating the right upperhypochondriac region ofthe abdomen of a client. What organ lies underneath this area. A. Duodenum B. GastricPylorus C. Liver D. Spleen C. Liver A client comesto the antepartal clinic and tellsthe nurse that she is 6 weeks pregnant.Which sign is she most likely to report? A. Decreased sexuallibido B. Amenorrhea C. Quickening D. Nocturia B. Amenorrhea A client's daughterphonesthe charge nurse to reportthatthe night nurse did not provide good care for her mother. What response should the nurse make? 2 A. Ask for a description of what happened during the night B. Tell the daughterto talk to the unit's nurse manager C. Reassure the daughterthatthe motherwillget better care. D. Explain that all the staff are doing the bestthey can. A. Ask for a description of what happened during the night A hosptitalized toddlerwho isrecovering froma sickle cell crisis holds a toy and say's "mine". According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage? A. Autonomy vs. Shame and doubt. B. Industry vs. Inferiority C. intiative vs.Guilt D. Trust vs. Mistrust A. Autonomy vs. Shame and doubt. Which action should the nurse implementin caring for a client following an electroencephalogram (EEG)? A. Monitorthe client's vitalsigns q4h B. Assessforsensation in the client'slowerextremities C. Instructthe client tomaintain bed restforeight hours D. Wash any paste fromthe client's hair and scalp D. Wash any paste fromthe client's hair and scalp The nurse is caring for a 75- year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpfullin preventing furtherdevelopment ofthe decubitus? A. Encourage the client to eat foods high in protein 3 B. Assessthe clientwith daily range of motion exercises C. Teach the family how to performsterile wound care D. Ensure the IV fluids are administered as prescribed A. Encourage the client to eatfoods high in protein What is the homeostatic cellular transportmechanismthatmoves waterfroma hypotonic to a hypertonic fluid space? A. Filtration B. Diffusion C. Osmosis D. Active transport C. Osmosis The nurse is taking blood presure of a client admitted with a possible myocardial infarction. When taking the client's BP at the brachial artery, the nurse should place the client's arm in which position? A. Slightly above the levelofthe heart B. At the levelofthe heart C. Atthe levelof comfortforthe client D. Below the levelofthe heart B. Atthe levelof the heart What are the final parametersthat produce blood pressure? (select allthat apply) A. Heart rate B. Stroke volume C. Peripheralresistance D. Neuroendocring hormones 4 E. Muscle tone A. Heart rate B. Stroke volume C. Peripheralresistance A client begins an antidepressant drug during the second day of hospitalization. Which assessmentis most important for the nurse to include in this client's plan of care while the client is taking the antidepressant? A. Appetite B. Mood C. Withdrawl D. Energy level B. Mood Based on the documentation in the medicalrecord, which action should the nurse implement next? A. Give the rubella vaccine subcutaneously B. Observe the motherbreastfeeding herinfant C. Call the nursery forthe infant's blodd type result D. AdministerVicodin one tabletforpain A.Give the rubella vaccine subcutaneously Upgrade to remove ads Only $3.99/month A clientis admitted to the hosptial with a diagnosis of Pneumonia. Which intervetion should the nurse implement to prevent complications associated with Pneumonia? A. Enourage mobilization and ambulation 5 B. Encourage energy conservation with completebed rest C. Provide humidified oxygenpernasal cannula D. Restrict PO and intravenousfluids A. Enourage mobilization and ambulation The practical nurse is preparing to administer a prescription for cefazolin (kefzol) 600 mg IM every 6 hours. The available vial is labeled, "Cefazolin (Kefzol) 1gramand the instrutionsforreconsittution, "For IM use add 2ml sterile water for injection. Total volume after reconstruction = 2.5 ml. "when reconstituded, how many milligrams are in each mil of solutions (Enter numeric value only) 15 Which nursing activity is within the scope of practice for the practical nurse? A. Complete an admission assessmentin the normalnewborn nursery. B. Discontinue a centralvenous catheterthat has become dislodged C. Observe a clientrotate the subcutaneoussite for an insulin pump D. Monitor a continous narcotic epiduralfor a postoperative client C. Observe a clientrotate the subcutaneoussite for an insulin pump Aftermorning dressing changes are completed, amale clientwho has paraplegia contaminates his ischial decubiti dressing with a diarrheal stool. What activity is best for the nurse to assign to the unlicensed assistive personnel? A. Identify the needfor additionalsuppliesto provide an extradressing change B. Provide perianal care and collect clean linensfor the dressing change C. Documentthe diarrhea that necessitates an additionaldressing change D. Position the client for accessto the decubitisties and remove dressings B. Provide perianal care and collect clean linensfor the dressing change The nurse is planning to evaluate the effectiveness ofseveraldrugs administered by differentroutes. Arrage the routes of administration in the order from fastest to slowest rate of absorption. 6 Subcutaenous Intravenous Intramuscular Sublingual Oral Intravenous,sublingual, intramuscular, subcutaneous, oral. A 26-year-old gravida 4, para 0 had a spontaneous abortion at 9 weeks gestation. At one-house post dilation and curettage (D&C) the nurse assessthe vitalsigns and vaginal bleeding. The client beginsto cry softly. How should the nurse intervene? A. Offerto call the social workerto discuss the possiblity of abortion B. Reassure the clientthatthe infertility specialist can help C. Expresssorrow forthe client's grief and offerto sit with her D. Chart the vitalsigns and amount of vaginal bleeding C. Expresssorrow forthe client's grief and offerto sit with her A terminally ill male client and his family are requesting hospice care afterdischarge fromthe hosptial and ask the nurse to explain what kind of care they should expect. The nurse should indicate that hospice philosophy focuses on what aspect of health care? A. Enhance symptommanagementto improve end of life quality B. facilitates assisted suicide with the client's consent C. Offers waysto postpone the deathexperienceat home D. Provide training for familymembersto care forthe client. A. Enhance symptommanagementto improve end of life quality The nurse observes awife shaving herhusband's beard with a safety razorby holding the skin taut and shaving in the direction of the hair growth . What action should the nurse take? 7 A. Advise the wife to shave againstthe hair growth B. Teach the wife to keep the skin loose to avoid cuts C. Encourage the wife to continue shaving herhusband D. Demonstrate the correct procedure to the wife C. Encourage the wife to continue shaving herhusband To assess pedalpulse what arterialsites should the nurse palpate? (select allthat apply) A. Posteriortibialis artery B. Politeal artery C. Externalfemoralartery D. Dorsalis pedis artery E Radial artery A. Posteriortibialis artery, D.Dorsalis pedis artery The nurse is admitting a client who is diagnosed withAnginaPectoris. Which precipitating factorin this client's history is likely to be related to the anginal pain? A. Smokes one pack of cigarettes daily B. Drinks two beers daily C. Worksin a job that requires exposure to the sun D. Eats while lying in bed A. Smokes one pack of cigarettes daily Upgrade to remove ads Only $3.99/month 8 The nurse is assessing an older resident of a long-term care facility who has a history of Benign Prostatic Hypertrophy and identifies that the client's bladder is distended. The healthcare provider prescribes post-voided residual catherterization over the next 24 hours and placement of an indwelling catheter if the residual volume exceeds 100 mL. The client's POintake is 600 mL, and fifteenminutes ago,the client voided 90 mL. What action should the nurse take? A. Stand the client to void and run tap waterwithin hearing distance before catheterizing the client. B. Straight catheterize and ifthe residual uring volume is greaterthan 100 mL, clamp catheter C. Catheterize q2Hand place in an indwelling catheter atthe end ofthe prescribed 24hr period. D. Catheterize with an indwelling catheter and if the residual volume is greaterthan 100 mL. Inflate the balloon. D. Catheterize with an indwelling catheter and if the residual volume is greaterthan 100 mL. Inflate the balloon. A client is receiving dexamethasone (Hexadrol, Decadron).Whatsymptomsshould the nurserecognize as Cushionoid side effects? A. Moon face, Slow wound healing,muscle wasting sodiumand waterretention B. Tachycardia hypertension,weightloss,heatintolerance, nervousness,restlessness,tremor C. Bradycardia, weight gain, cold intolerance, myxedema facies and periobarbitaledema D. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension A. Moon face, Slow wound healing,muscle wasting sodiumand waterretention The cervix is the opening into the uterine cavity. What is its function in reproduction? A. Accepts and interpretssignals ofsexualstimuli B. Secretesmucusto facilitate spermtransport C. Serves asthe site forunion of ovumans sperm D. Receivesthe penis during intercourse B. Secretesmucusto facilitate spermtransport 9 The nurse is working in a community health setting and assisting the charge nurse in performing health screenings. Which individual is at highest risk for contracting an HIV infection? A. 17-year-old who issexually active simultaneously with numerous partners B. 34-yearold homosexualwho isin a monogamousrelationship C. 30-year-old cocaine userwho inhales and smokes drugs D. 45-year-old who hasreceived two blood transfusionsin the past 6 months A. 17-year-old who issexually active simultaneously with numerous partners The nurse is administering amiodarone (Cordarone) to a client who has been admitted withAtrial Fibrillation (AFIB). What therapeutic response should the nurse anticipate? A. Conversion of irregularheartrate to regularheartrhythm B. Pulse oximetry readings within normalrange during activity C. Peripheralpulse points with adequate capillary refill D. Increase excercise tolerancewithoutshortness of breath A. Conversion of irregularheartrate to regularheartrhythm An elderlymale clientis planning to vacation with a group ofsenior citizens.He is concerned about developing constipation during the airplane flight. He share this concern with the nurse at the retirement home. Which recommendation is best for the nurse to provide? A. Use an overthe counterstoolsoftenerwhen needed B. Eat a high protein diet C Increase the fluid intake in yourdiet D. Decrease the fat contentin yourdiet C. Increase the fluid intake in your diet The nurse is assessing a clientwith dark skin who is in Respiratory Distress. Which client response should the nurse evaluate to determine cyanosis in this particular client? 10 A. Abnormalskin color changesin a client with dark skin cannot be determined B. Blanching the soles ofthe feetin a client with dark skin reveals cyanosis C. The lips and mucusmembranes of a client with dark skin are dusky in color D. Cyanosisin a client with dark skin is seen in the sclera C. The lips and mucusmembranes of a client with dark skin are dusky in color When inserting an indwelling urinary catheter(Foley) in a female client,the nurse observes uring flow into the tubing. What action is taken next? A. Documentthe color and clarity ofthe urine B. Insertthe catheter an additionalinch C. Ask the client to breathe deeply and slowly exhale D. Inflate the balloon with 5mL ofsterile water B. Insertthe catheter an additionalinch A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a lumber Laminectomy. Whatinformation should the nurse reinforce about the action of this adjuvant pain modality? A. Mild electricalstimulus on the skin surface closesthe gates of nerve conduction forseverpain B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electricalstimulus C. An infusion of medication in the spinal canal will block pain perception D. The discharge of electricity will distractthe client's focus on the pain B. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus Based on the Nursing diagnosis of "Potentialforinfection related to second and third degree burns," which intervention has the highest priority? A. Application oftopical antibacterial cream 11 B. Use of carefulhand washing technique C. Administration of plasma expanders D. Limiting visitors to the burned client. B. Use of carefulhand washing technique Upgrade to remove ads Only $3.99/month The motherof an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder, which assessment finding is the most significant indicator of possible child abuse? A. The child looks at the floore when answering the nurse's questions B. The mother's version ofthe injury is differentfromthe child's version C. The child hasseveralabrasions on the chest and legs D. The motherrefusesto answerquestions aboutfamily history D. The motherrefusesto answerquestions aboutfamily history A client has a prescription forenteric-coated (EC) aspirin 325mg POdaily. The medication drawer contains one 325mg aspirin. What action should the nurse take? A. Contactthe pharmacy and requestthe prescribed formof aspirin B. Instructthe client about the effects when given the medication C. Administerthe aspirin with a full glass of wateror a small snack D. Withhold the aspirin until consultingwith the healthcare provider C. Administerthe aspirin with a full glass of wateror a smallsnack The nurse explainsthe 2-week dosageprescription of prednison (Deltasone) to a client who has poison ivy over multiple skin surfaces. What should the nurse emphasize about the dosing schedule? A. Decrease dosage daily as prescribed 12 B. Monitororal temperature daily C. Take the prednison withmeals D. Return forblood glucose monitoring in one week C. Take the prednison withmeals The nurse is preparing to administer a 1.2mL injection to a 4-year-old. Which are the bestsitesto administer an IM injection? Select all that apply. A. Vastuslateralis B. Ventrogluteal C. Dorsogluteal D. Rectusfemoris E. Deltoid A. Vastuslateralis B. Ventrogluteal C. Dorsogluteal Which nonfood itemisthe most common cause of respiratory arrestin young children? A. Broken rattles B. Buttons C. Pacifiers D. Latex balloons D. Latex balloons A newmotheris at the clinic with her4-week old for a well baby check up. The nurse should tellthe mother to anticipate that the infant will demonstrate which millstone by 2-months of age. A. Turnsfrom side to back and returns 13 B. Consistently returnssmilestomother C. Finds hands and plays with fingers D. Holds head up and supports weightwith arms B. Consistently returnssmilestomother The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen and teh infusion rate is slower than the prescribed rate. What is the most likely cause of this finding? A. The solution'srate is too rapid B. The client has phlebitis C. The infusion site is infected D. The infusion site is infiltrated D. The infusion site is infiltrated The nurse observesthat amale client's urinary catheter(Foley) drainage tubing issecured with tape to his abdomen and then attached to the bed frame. What action should the nurse implement? A. Raise the bed to ensure the drainage bag remains offthe floor B. Attach the drainage bag to the side rail instead ofthe bed frame C. Observe the appearance ofthe urine in the drainage tubing D. Secure the tubing to the client's gown instead of his abdomen C.Observe the appearance ofthe urine in the drainage tubing In assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next? A. Advise the clientthat suctioningwill be used to obtain anotherspecimen B. Re-instructthe clientin coughing techniquesto obtain anotherspecimen C. Provide the client a glass of water andmouthwash to rinse the mouth 14 D. Labelthe container and place the containerin a bio-hazard transport bag B. Re-instructthe clientin coughing techniquesto obtain anotherspecimen Afterreport,the nurse receivesthe laboratory valuesfor4clients. Which client requiresthe nurse's immediate intervention? The client who is..... A. short of breath after a shower and has a hemoglobin of 8 grams B. Bleeding froma fingerstick and has a prothrombin time of 30 seconds C. Febrile and has a WBC count of 14,000/mm3 D. Trembling and has a glucose levelof 50 mg/dL D. Trembling and has a glucose levelof 50 mg/dL Upgrade to remove ads Only $3.99/month 4 hours after administration of 20U ofregular insulin, the client becomesshakey and diaphoretic. What action should the nurse take? A. Encourage the client to excercise B. Administer aPRN dose of 10U ofregular insulin C. Give the client crackers andmilk D. Record the client's reaction on the diabetic flow sheet C. Give the client crackers and milk The nurse is changing the colostomy bag for a client who is complaining of leakage of diarrhealstool under the disposable ostomy bag. What action should the nurse implement to prevent leakage? A. Place a 4X4 wick in the stoma opening B. Apply a layerof zinc oxide ointmentto the perimeterofthe stoma C. Cutthe bag opening to the measurement ofthe stoma size 15 D. Administer aPRNantidiarrheal agent C. Cut the bag opening to the measurementofthe stoma size Prior to administeringmorphine sulfate (Morphine),the nurse takesthe client's vitalsigns. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified? A. Temperature of 100.8F B. A pulse rate of 150 beats perminute C. A respiratory rate of 10 breaths perminute D. A blood pressure of 180/110 C. A respiratory rate of 10 breaths perminute Following an open reduction ofthe tibian, the nurse notesfresh bleeding on the client's cast. Which intervention should the nurse implement? A. Assessthe client's hemoglobin to determine ifthe clientisin shock B. Call the surgeon and prepare to take the client back to the operating room C. Outline the area with ink and check it q15 minutesto see ifthe areahas increased D. No action is required since postoperative bleeding can be expected C. Outline the areawith ink and check it q15 minutesto see ifthe area hasincreased The nurse is with a client when the healthcare provider explainsthatthe biopsy classifiesthe results as a T1N0M0 tumor. Later in the morning, the client asks the nurse, "what do these letters T1N0M0, stand for?" which response should the nurse provide first? A. "The letters are used to predict the prognosis ofthe canceror tumor." B. "The lettersstand fortumorsize, node involvement andmetastasis." C. "Letme refer you to the charge nurse." D. "Are you confused? Would you like to talk?" 16 B. "The lettersstand fortumorsize, node involvement andmetastasis." The nurse plans to administerthe rubella vaccine to a postpartumclient whose titeris 1:8 and who is breastfeeding? what information should the nurse provide this client? A. The client should bottle feed and pump herbreastfor3 daysfollowing immunization B. The vaccine is given to produce maternalantibodies beforelactation occurs C. The infantwill receive immunization through the mother's breastmilk D. The client should not get pregnantfor3 months afterimmunization B. The vaccine is given to produce maternalantibodies beforelactation occurs In counting a client's radial pulse,the nurse notesthe pulse isweak and irregular. To record the most accurate heart rate, what should the nurse take? A. Recheck the radial pulse in thirtyminutes B. Palpate the radial pulse forthiry seconds and double the rate C. Countthe apical pulse rate forsixty seconds D. Compare the radial pulse rate bilaterally and record the higherrate. C. Countthe apical pulse rate forsixty seconds Which structures are located in the subcutaneouslayerofthe skin? A. Sebaceous and sweat glands B. Melanin and Keratin C. Sensory receptors and hairfollicles D. Adipose cells and blood vessels D. Adipose cells and blood vessels The nurse in charge of a Nursing unit in a long term care facility. Which task is bestfor the nurse to assign to an unlicensed assistive personnel (UAP) who is helping with the care of several clients? 17 A. Measure the amount of a client'sresidual urine after voiding B. Cleanse the perinealareaof a client with urinary incontinence C. Insert a straight catheterto obtain a urine specimen for culture D. Provide catheter care for a clientwith a suprapubic catheter B. Cleanse the perinealareaof a clientwith urinary incontinence A client requires application of an eye shield to the right eye. Whatshould the nurse do in orderto apply tape in which direction to anchor the shield most effectively? A. Acrossthe eye fromthe bridge ofthe nose to the right temple B. Longitudinally fromthe rightforehead to the right cheek C. Fromthe mid-forehead overto the rightzygomaticprocess D. Fromthe right lateral forehead surface to the medialnasal crease B. Longitudinally fromthe right forehead to the right cheek Upgrade to remove ads Only $3.99/month 36 hours afterdelivery,the nurse determinesa client'sfundusis just above the umbilicus and displaced to the right of midline. What action should the nurse take first? A. Palpate the bladderfor distention B. Ask the client when herlast bowelmovement occurred C. Catheterize the client and record the amount D. Assessthe amount of lochia A. Palpate the bladder fordistention A client presentsin the clinic because of generalized swelling after abee sting. What intervention should the nurse implement first? 18 A. Assesssite ofsting and remove stingerif present B. Performmini-mentalstatus examto assesslevelof consciousness C. Determine respiratory status and apply apulse oximeter D. Attach electrodestomonitor cardiac rhythm C. Determine respiratory status and apply apulse oximeter The nurse is administeringmultiple medicationsto a 78-year-old client because of problemsrelated to polypharmacy. At this client's age, which assessment is most important for the nurse to make? A. Cumulative serumdrug levels and toxicity B. Synergistic actions due to simultaneous administration C. Tolerance to drugs that have been taken forlong periods oftime D. Antagonist actions of multiple medications A. Cumulative serumdrug levels and toxicity In obtaining an orthostatic vitalsign measurement, what action should the nurse take first? A. Countthe client'sradial pulse B. Apply a blood pressure cuff C. Instructthe client to lie supine D. Assistthe client to stand upright C. Instructthe clientto lie supine A 3-week-old infantis admitted forsurgical repair of Pyloric Stenosis. Whatinterventionsshould the nurse expect to implement to establish hydration in the immediate postoperative period? A. Diaper weights and urin specific gravity B. Gastronomy feedingsin supine position 19 C. Nipple feedings with glucose water D. Gavage feedings with 15mLof formula C.Nipple feedings with glucose water Urinary catheter(Foley) with a5mL inflated balloon is being removed by the nurse. Afterwithdrawing 5 mL of fluid from the balloon, the nurse begins to withdraw the catheter while the client is in a SemiFowler's position. However,the nurse meetsresistance and the clients voicees discomfort. What action should the nurse take next? A. Attempttowithdraw additionalfluid fromthe balloon B. Assistthe client in taking a series of deep breaths C. Lowerthe head ofthe client's bed so the client is supine D. Allow the client to rest before continuing to remove the catheter B. Assistthe clientin taking a series of deep breaths The home health nurse observes an elderly male client attempt to open a child-proof medication container. When he is unsuccessful in opening the container, he throwsit across the roomand curses loudly. What action should the nurse implement? A. Transferthe medicationsto anotherbottle thatis easierto open B. Leave the client's home immediately and plan to return later C. Igonore the outburst and demonstratehow to open the bottle D. Describe othertypes of medication containersthat are available D. Describe othertypes of medication containersthat are available At 7AM, a Diabetic client is conscious with a serumglucose levelof 50mg/dL. To manage this client's care effectively, what should the nurse administer? A. Orange juice B. Glucagon C. 10 units of regularinsulin 20 d. IV of 5% glucose in water at 100 mL/hr A.Orange juice A nurse is caring for a client with Multiple Sclerosis (MS) who is receiving an immunsupressant. Which action is mostimportant forthe nurse to implementto evaluate for adverse effectsfromthis particular medication? A. Observe the client'sskin forbruising B. Auscultate the client's bowelsounds C. Monitorthe clients intake and output D. Note changesin the client's weight D. Note changesin the client's weight Amale client withHypercholesterolemia is being discharged with anew prescription forsimvastatin (Zocor). The client tells the nurse that he understands it is important to have liver tests performed periodically. How should the nurse respond? A. Instructthe client thatthe only regular testing needed istomonitorhis cholesterol level B. Teach the client that livertest are usually only done ifthe client reportssymptoms C. Review with the clientthat renalfunction tests are needed,ratherthan livertests D. Confirmthatthe client correctly understandsthe needtomonitorliverfunction regularly D. Confirmthatthe client correctly understandsthe needtomonitorliverfunction regularly An obese female clientwith a high serumcholesterol level comesto the clinic for a follow-up evaluation. She tells the nurse that she is now walking 30 minutes three times per week and is eating a carbohydrate free, high protein diet in order to lose weight. What response is best for the nurse to provide? A. Explain to the client that herdiet choice is not helpfulin lowering cholesterol levels B. Discussthe importance of maintaining a target heartrate during each exercise period C. Teach the client additional waysto lower cholesterol, including stressmanagement 21 D. Praise the client forherexercise and dieting efforts and encourage herto continue with this program A. Explain to the clientthat herdiet choice is not helpfulin lowering cholesterollevels A child with Chronic Asthma is scheduled forChest Physiotherapy. When should the nurse administer the meter-dosed inhalar (MDI) puff of bronchodilator relative to postural drainage treatments? A. Before posturaldrainage B. During posturaldrainage C. Afterposturaldrainage D. Between treatements C. Afterposturaldrainage A client has a prescription for lorazepam(ativan) 1mg for anxiety. The medication issupplied as 0.5mg tablets. How many tablets should the client take? (enter numeric value only. 2 The nurse is caring for a middle-aged clientwho had a Myocardial infarction (MI) 3days ago. Which finding is most important for the nurse to report? A. Frothy red-tinged sputum B. Irregularheartrate C. Two pound weight gain D. Dependent edema B. Irregularheartrate A clientis diagnosed with ClostridiumDifficile (CDIFF). What action should the nurse implementto prevent the spread of the organism? A. Place a surgical mask on the client during transport B. Don non-sterile gloves when performing direct care 22 C. Wear a particular respiratormask when in the room D. Keep the door closed to the client's roomat all times B. Don non-sterile gloves whenperforming direct care A 67-year-old woman who lives alone tripped on a rug in her home and fractured her right hip. The nurse knowsthatwhich predisposing factor contributesto the occurrence of hip fractures among elderly women. A. Urinary retention resulting in renal calculi formation B. Failing eyesightresulting in an unsafe environment C. Osteoporosisresulting fromhormonal changes D. Transientischemicattacks (TIAs) which impairmentalactivity C.Osteoporosisresulting fromhormonal changes An elderly client is admitted for evaluation of Alzheimer's disease. At 2AM, the nurse finds the client trying to open the emergency door. Whatisthe most appropriate response forthe nurse tomake in this situation? A. "This is the emergency door. Are you looking forthe bathroom?" B. "You look confused. Would you like to talk about yourfeelings?" C. "Let's go back to your room. Yourdoctor does notwant you to be walking alone." D. "You want to go outside at thistime of night? It's dangerous outthere." A. "This is the emergency door. Are you looking forthe bathroom?" Which nurse's behavioris a breach of client confidentiality according to the Health Insurance Portable Accountability Act (HIPPA) regulations? A. A daily reportsheetwith the information ofthe team's clientsis taken home. B. Privileged health information (PH) ismailed through the US postalservice C. A client is called by both the first and last name in a public waiting room. 23 D. The ambulance health care provideris given information aboutthe client's history A. A daily reportsheetwith the information ofthe team's clientsis taken home. A clientis returning to the surgical unit after a totalright knee replacement. Which assessmentfindings are most important for the nurse to include in this client's record? A. Pedalpulses, pallor, pain, paresthesia orparalysis B. Levelof consciousness, lung sounds, and bladdertone C. Swallow reflex, nausea, and vomiting and IV infusion rate D. Call bellside rails, bed in position, and ambulation aids A. Pedalpulses, pallor, pain, paresthesia orparalysis The nurse is standing at the clinic desk when amother and preschool child approach. The mothertells the nurse that her child has a fever and rash. What action should the nurse take? A. Take the child immediately to a different part ofthe clinic B. Have themwait in the waiting area away from the other children C. Tell the motherto return to the clinic when the rash subsides D. Place themfirst on the list to see the healthcare practitioner B. Have themwait in the waiting area away from the other children A nurse is contributing to a care plan for an adolescentfemale clientwithAnorexiaNervosa.Which outcome statement or goal would be most appropriate for this client? A She will participate in a daily aerobicexercise program B. She will consume atleast 50 percent of all meals C. Herlaboratory values willremain within normallimits D. She will develop apositive body image and self-identity D. She will develop apositive body image and self-identity 24 A female clientwith no family history of Breast Cancer(BA) asksthe nurse how often she should obtain a Mammogram. Which additional client information should the nurse obtain before answering this client's question? A. Current age B. Breastsize C. Breastfeeding history D. Menopausalstatus C. Breastfeeding history The nurse is working on the postpartum unit and is assisting a new mother with her newborn's diaper change. The mother states that the infant fed well and completed the whole bottle of formula. What action should the nurse implement first when the infant begins to spit up during the diaper change? A. Bubble orburp the infant by patting the infant's back B. Encourage the motherto avoid overfeeding the infant C. Turn the newborn and bulb suction the mouth and nose D. Wipe away the secretions and finish the diaper change C. Turn the newborn and bulb suction the mouth and nose An older male client tells the nurse that his religion does not permit him to bathe daily. How should the nurse respond? A. Review the importance of hygienicmeasuresforimproved health B. State thatthe healthcare providerhas prescribed abath today C. Offerthe clientseveral choices oftimesto bathe during the day D. Requestthatthe client clarify his religious beliefs about bathing D. Requestthatthe client clarify his religious beliefs about bathing A new father asksthe nurse the reason forplacing an ophthalmicointmentin his newborn's eyes.What information should the PN provide? 25 A. Possible exposureto an environmentalstaphylococcusinfection can infectthe newborn's eyes and cause visual deficits B. The newborn is at risk forblindnessfroma cornealsyphilitic infection acquired froma mother's infected vagina C. Treatment preventstearduct obstruction with harmfulexudatefroma vaginalbirth that can lead to dry eyes in the newborn D. State law mandates all newbornsreceive prophylactic treatmentto preventgonorrhealor chlamydial ophthalmic infection D. State lawmandates all newbornsreceive prophylactic treatmentto prevent gonorrhealor chlamydial ophthalmic infection The scope of practice forthe practical nurse includes which client assessments? A. An agitated client with bilateral wristrestraints B. New admission of a client with deep vein thrombosis C. Return of a postaneshesia clientfollowing a colon resection D. Transferof a client with sepsisfroma long-termcare facility D. Transferof a clientwith sepsisfroma long-termcare facility What skin care measure should the nurse implementfor a clientwho underwent an externalradiation treatment the previous day? A. Cleanse the radiated areawith water and pat the skin dry B. Lightly massage the radiated skin with a lanolin-based lotion C. Rinse the site with normalsaline and coverwith a sterile towel D. Use ofsoftwashcloth to gently remove the skinmarkings A. Cleanse the radiated areawith water and pat the skin dry Which organ laysretroperitoeally? 26 A. Kidneys B. Testicles C. Urinary bladder D. Pancreas A. Kidneys The nurse is caring for a client with MyastheniaGravis. Whattime of day is bestforthe nurse to schedule physical excercises with the physical therapy department? A. Before bedtime,at 2000 B. Afterbreakfast C. Before the eveningmeal D. Afterlunch B. Afterbreakfast The nurse is planning to ambulate client who has been on bed restfor 24 hoursfollowing a Colon Resection. To ambulate this client safely, which intervention should the nurse implement first? A. Place non-skid shoes on the client B. Show the client how to use the call light C. Use a gait beltto supportthe client D. Assistthe client to a bedside sitting position D. Assistthe client to a bedside sitting position A Clientis admitted to the hospitalwith second and third degree burnsto the face and neck.How should the nurse best position the client to maximize function of the neck and face and prevent contracture? A. The neck extended backward using a rolled towelbehind the neck B. Prone position using pillows to support both arms outward fromthe torso 27 C. Side-lying position using pillows to supportthe abdomen and back D. The neck forward using pillows underthe head and sandbags on both sides A. The neck extendedbackward using a rolled towelbehind the neck A clientreceives anew prescription forthe angiotensin IIreceptor antagonistlosartan (Cozaar). Which client instruction should the nurse encourage this client to follow? A. Move slowly when getting up to preventsuddendizziness B. Take this medication with or aftermeals C. Do notstop this medication until all ofthe tablets are gone D. Keep the dietary log during initial therapy A. Move slowly when getting up to preventsuddendizziness The healthcare providerprescribes erythromycin (ilosone) 300mg POQID. The medication label reads, "ilosone 100mg/5mL" How many mL should the nurse administer at each does? (Enter the numeric value only) 15 The nurse is monitoring a client with an IV infusion in the left antecubitalfossae. The infusion pump is functioning without alarms at the prescribed rate of 100mL/hour. The site is warm, red and without swelling. What conclusion should these findings indicate to the nurse? A. The IV fluids are infusing into the subcutaneoustissues and the pump should be stopped B. The infusion pump is functioning properly and the IV site is healthy C. The insertion date should be verified and the IV discontinued D. The site is inflamed and should be reported to the RNforplacementin anothersite. D. The site is inflamed and should be reported to the RNforplacementin anothersite. The nurse reviewesthe laboratory results of a client whose serumpHis 7.38 on the pH scale what does this value imply about the clients homeostasis 28 A. Alkalosis B. Acidosis C. NormalserumPH D. Incompatible with life C. NormalserumPH The nurse plans to assess a newborn and to check the infant's Moro reflex. In assessing thisreflex,the nurse is evaluating which parameter? A. Neurological integrity B. Renalfunctioning C. Thermogenic regulation D. Respiratory adequacy A.Neurological integrity The nurse assigns an unliscensed assistive personnel(UAP)to feed a clientwho is at risk for aspirations. To ensure that the task is safely delegated what action should the nurse implement? A. Informthe UAP thatthe suction is available at the bedside B. Instructthe UAP to notify the PNif the client beginsto choke C. Observe the UAP's ability to implement precautions during feed D. Ask the UAP about previous experience performing thisskill C.Observe the UAP's ability to implement precautions during feed The unlicensed assistive personnel(UAP)reportsto the nurse that a client refused to bathe forthe third consecutive day. What action is best for the nurse to take? A. Ask the client why the bath wasrefused B. Ask familymembersto encourage the clientto bathe C. Explain the importance of good hygiene to the client 29 D. Reschedule the bath forthe following day A. Ask the client why the bath wasrefused An adult female client is admitted to the psychiatric unit with diagnosis of major depression. After 2 weeks of antidepressantmedication therapy,the nursenoticesthe client hasmore energy, is giving her belongings away to her visitors, and is in an overall better mood. Which intervention is best for the nurse to implement? A. Tell the client to keep herbelongings because she willneed thematdischarge B. Ask the client if she has had any recentthoughts of harming herself C. Reassure the clientthatthe antidepressant drugs are apparently effective D. Supportthe client by telling her whatwonderfulprogresssheismaking. B. Ask the client if she has had any recentthoughts of harming herself In assisting a client performpursed lip breathing,the nurse should ensure thatthe client performs which action? A. Inhale through the nose with the mouth closed and exhale through pursed lips B. Inhale through pursed lipsthen exhale with the mouth held open C. Inhale through pursed lips and then exhale through the nose with the mouth closed D. Inhale through the mouth puffthe cheeksand exhale through pursed lips A. Inhale through the nose with he mouth closed and exhale through pursed lips A 3 year-old admitted with feverof unknown origin (FUO) has begun vomiting in the past half hour. The child's temperature is 101.80 F, and the last dose of antipyretic medication was given 5 hours ago. The child has prescriptions of acetaminophen (Tylenol) 160 MG per5 mL elixir or 160 mg suppositories PRN fever orpain. What action should the nurse take at this time? A. Make the child NPOand hold all medications untill the vomiting has stopped B. Give acetaminophen elixirto ensure the child's cooperation with swallowing C. Notify the healthcare providerthatthe child'sfeverhas become dangerously high 30 D. Use an acetaminophen suppository forthe feversince the child is vomiting A. Make the child NPOand hold all medications untill the vomiting has stopped A clientis havingRadical Masectomy. Whatisthe position of choice during the immediate postoperative period? A. Side-lying on the operative side with the bed flat B. Supine with the arm on the operative side in a dependent position C. Semi-Fowler's position with the armon the operative side elevated D. Sim's position with the armon the operative side in a dependent position C. Semi-Fowler's position with the armon the operative side elevated The nurse assessesthe perineumof a client 12 hours after a normalvaginal delivery and findsthatshe has Perineal Hematomas. The nurse should prepare for which treatment? A. Heatlamp three times perday B. Insertion of vaginal packing C. Cold packsto the perineum D. Operative excision ofthe hematomas C. Cold packs to the perineum A client at 28 weeks gestation is admitted to the antepartum unit and is being treated for preterm labor. She has a prescription for brethine (Terbutaline) 250 micrograms subcutaneously q4h. The medication is available for injection in 1 mg per ML vials. How many mL should the nurse administer? A. 0.025 B. 0.0025 C. 0.25 D. 25.0 C. 0.25 31 A school-aged child withAIDS is exposed to an active case of Varicella. The nurse should recommend that the family take which action? A. Obtain penicillin G 1000U weekly B. Obtain the varicella vaccine C. Enroll in a home schoolprogram D. Obtain the varicella zosterimmune globulin D. Obtain the varicella zosterimmune globulin The principle of client advocacy is best demonstrated when the nurseexhibits which behaviors on behalf of the client? A. Nurse who contacts child protective servicesto report amother's decision to refuse vaccination for her firstborn infant B. Nurse refusing to care for a convicted rapist stating that personaldiscomfortwould inhibit provision of quality of care C. Nurse who translates complaintsfor a Spanish-speaking clientto the healthcare providerduring rounds D. Nurse sharing information aboutlife afterdeath with a grieving family who justlost a loved one C. Nurse who translates complaintsfor a Spanish-speaking clientto the healthcare providerduring rounds The nurse is preparing a client for an Intravenous Pyelogram(IVP)scheduled forthe followingmorning. What action is most important for the nurse to implement? A. Determine ifthe client has any allergies to shellfish B. Informclientthat an IV dye will be administered before the IVP C. Explain that dizzinessmay occur when the dye is given D. Administer abowelprep the evening beforethe procedure A.Determine ifthe client has any allergiesto shellfish 32 A nurse refusesto performaprocedure because itis beyond the scope of practice for practical nurses. Which resource best defines the nurse's legal responsibility in regard to scope of practice? A. Nursing practice standardsfor Licensed Practical/VocationalNurses B. State Nurse Practice Act C. Code of Ethicsfor Licensed Practical/VocationalNurses D. Patients Bill of Rights B. State nurse Practice Act While making the bed of a female clientwho is sitting in the bedside chair,the nurse observesthe client seem anxious. To encourage verbalization by the client, what action should the nurse take? A. Continue tomake the bed while conversing with the client B. Sit nextto the client at a slight angle to continue the conversation C. Remain standing close enough to the clientto hold herhand D. Bring a chair face-to-face with the clientforfurtherdiscussion B. Sit nextto the client at a slight angle to continue the conversation A clientis admitted forobservation afterexperiencing aTransientIschemicAttack (TIA). The nurse anticipates implementing care for which client problem? A. High risk for injury B. Altered breathing patterns C. Ineffectiveairway clearance D. High risk infection B. Altered breathing patterns An elderly postoperative client hasthe Nursing diagnosis, "Impairedmobility related to fearof falling." Which desired outcome best directs Nursing actions for this client? 33 A. The physical therapistwill instruct the client in the use of a walker B. The nurse will place a gait belt on the client prior to ambulation C. The client will ambulate with assistance q4h D. The client will use self-affirmation statementsto decrease fear C. The client will ambulate with assistance q4h A female client complainsto the nurse about being admitted to a semi-private roomand expresses her displeasure because she requested a private room prior to admission. What response is best for the nurse to provide this client? A. Roomassignments are based on client's acuity level, not necessarily by request B. I will place yourname on the roomrequestlist forthe next available private room C. Yourhealthcare providermust provide awritten requestto get you a private room D. There are no private rooms available, so you will have to stay here forthe time being. C. Your healthcare providermust provide awritten requestto get you a private room During preoperative preparation,the nurse should offerthe clientwhich explanation aboutwhy deep breathing exercising with an incentive spirometer are necessary after surgery? A. "Deep breathing exercises using spirometerwillhelp preventpostoperativecomplications." B. "failure to keep yourlungs workingmay resultin pneumonia and death." C. "Incentive spirometry is uncomfortable but necessary for yourpostoperative care." D. "You will use the spirometerforthe first postoperativeday only." A. "Deep breathing exercises using spirometerwillhelp prevent postoperative complications." The nurse is caring for a client who had a total Laryngectomy, Left Radical Neck Dissection, and tracheostomy. The clientis receivingNasogastric (NG) tube feedings via an enteralpump. Today the rate of the feeding was increased from 50mL/hr to 75mL/hr. What parameter should the nurse evaluate the client's tolerance to the rate of feeding? 34 A. Bowelsounds B. Urinary and stool outputs C. Gastric residual volumes D. Daily weight C.Gastric residualvolumes A client is admitted with a feverof undermined origin (FUO). During rounds,the nurse findsthe client diaphoretic, and the linens are damp. What should the nurse do first? A. Change the bed linen to prevent chilling B. Check the client's vital signs and pain scale C. Assessthe clientforurinary incontinence D. Determine fluid intake forthe past 8 hours B. Check the client's vitalsigns and pain scale Which client should the nurse assign to an unlicensed assistive personnel(UAP)? A. An older male client with melenawho is complaining of abdominal pain and needs a guaic test of a stool sample B. A young adult experiencing flank pain and hematuriawho needs allurine strained forstones C. A client who has regularheartrate and after a pacemakerreplacement now needsto ambulate D. An elderly client with Right-SidedHemiplegia and Receptive Aphasiawho needsto be transfered to the wheelchair C. A client who hasregular heartrate and after a pacemakerreplacement now needsto ambulate The nurse is administering the shingles vaccine to an oldermale-clientwho asks why he should receive the immunization. Which information should the nurse provide? A. A history of chickenpox indicatesthatthe harborsthe dormant virus B. The client's last dose of adult immunizations was 10 years ago 35 C. A recent outbreak of feverblistersindicatesreactivation ofthe virus D. Multiple stressfulpersonalexperiencesincrease hisrisk ofshingles A. A history of chickenpox indicatesthatthe harborsthe dormant virus In preparing a client for a lumbar puncture, what action should the nurse implement? A. Assistthe client to the bathroomto void B. Apply a pulse oximeterto the client'sfinger C. Teach the client to cough and deep breathing exercises D. Ensure thatthe client has beenNPOforsix hours. C. Teach the client to cough and deep breathing exercises A client who had a lobectomy two days ago has 2 chest tubes, each attached to a water-sealed drainage system, Pleur-Evac. The nurse observes that in the last 8 hours the serosanguineousfluid has diminished to output in the drainage chamber. What is the most likely outcome of this observation? A. Removalofthe lower chesttube, if a chest x-ray reveals no pleuralaccumulations B. Change the Pleur-Evac systemand re-assessoutputin the empty chamber C. An increase in the prescribed suction force to facilitate-drainage ofserosanguineousfluids D. Advance the chesttube to ensure properplacement ofthe tip to enhance drainage B. Change the Pleur-Evac systemand re-assess outputin the empty chamber While caring for a client who has been vomiting, the nurse notes that the client's breath has developed a fruity odor. What assessment should the nurse perform first? A. Auscultate the client's bowelsounds B. Determine the client's capillary glucose C. Observe the colorofthe client's urine D. Measure the client's oxygen saturation B.Determine the client's capillary glucose 36 The nurse is preparing to assist an elderly client to the bathroom. The nurse knows that an elderly adult's centerof gravity changesfromthe hips to another area ofthe body. Which areaof the body is the center of gravity for the elderly client? A. Uppertorso B. Head C. Feet D. Upper extremities A.Uppertorso A 60 year-old clientwith cancerof the liver is in Hepatic Coma and unresponsive. Whatshould the nurse say to family members who are inquiring about the condition of their loved one? A. "Yourloved one's condition is very critical, and there has been no response in the last 24 hours" B. "The nurses have not been able to arouse the client and the healthcare provider knowsthe outcome." C. "You need to discussthe condition with the charge nurse in a family conference." D. "The client's condition is extremely critical.Has yourfamilymade funeralarrangements?" A. "Your loved one's condition is very critical, and there has been no response in the last 24 hours" A client complains of kidney pain. The nurse understandsthatthe kidneys are located where? A. On the retroperitonealposterior abdominalwallat the costovertebralangle B. Within the curve ofthe duodenum, posteriorto the spleen C. Lateral to the stomach in the hypochondriac region D. Superior aspect ofthe bladderin right and leftiliac region A.On the retroperitonealposterior abdominalwallat the costovertebralangle The nurse receivesreport on an adult client who has a centralintravenous(IV) infusion. Where should the nurse observe when assessing the integrity of the access site? 37 A. Umbilical areaofthe abdomen B. Antecubitalfossae ofthe arm C. Chestwall below the clavicle D. Dorsalsurface ofthe hand C. Chestwallbelow the clavicle The healthcare providerprescribes an IV solution of clindamycin (Cleocin) 850mg in 75 mL of D2W to infuse over30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliverhow many gtt/minute? (Enter numeric value only. if rounding is required round to the nearest whole number) 75mL X 15gtt/mL= 38 38 The nurse is administering a subcutaneousinjection of epoetin (Epogen)to a client with ChronicKidney Disease (CKD). This medication is being administered to treat which manifestation of CKD? A. Anemia B. Anuria C. Hypotension D. Edema A. Anemia The nurse is assigned to administermedicationsin a long-termcare facility. A disoriented resident has no identification band or picture. Prior to administering medications to this resident, what is the best Nursing action? A. Confirmthe roomand bed numbers with those on the medication record B. Ask a regularstaff memberto confirmthe residentsidentity C. Hold the medication untill a family member arrives 38 D. Re-orientthe residentto name, place and situation. B. Ask a regularstaff memberto confirmthe residentsidentity The nurse is assessing an older male client with Gastritis. He has been unable to eat for the past 48 hours and has been vomiting during this same period oftime. Which finding can the nurse expectthis client to exhibit? A. Edemetouslowerextremities and an increased temperature B. A decreased temperature and increasedblood pressure C. Dry skin and an increased heartrate D. Diaphoresis and hypertension C. Dry skin and an increased heartrate An adult male client tells the nurse that he believes someone is trying to obtain his computer records, which his wife reports are recreational in nature. The client insiststhat an elaborate alarm systemneeds to be installed in his home. The nurse knows that this client is exhibiting which signs or symptom? A. Delusions of persecution B. Ideas ofreference C. Hallucinations D. Confabulation A.Delusions of persecution The nurse enters a client's roomto performa sterile dressing change. The nurse observesthatthe client is "gurgling" on oral secretions and coughing. Which action should the nurse take first? A. Position the client supine B. Fingersweep the oral cavity C. Performoralsuctioning D. Provide mouth care 39 C. Performoralsuctioning What length of blood pressure cuffshould be the nurse use when obtaining a client's blood pressure? A. A cuffthat is no longer than the circumference ofthe extremity should be used B. The length of the blood pressure cuff does notmake adifference C. The cuff and its bladdershould be nearly encircled in the extremity's circumference D. Atleasttwo-thirdsthe circumference ofthe extremityshould be covered C. The cuff and its bladdershould be nearly encircled in the extremity's circumference A nurse is assisting a client fromthe bathroomback to bed following a minorsurgical procedure. The client, still not fully alert, reports feeling nauseated and begins to vomit. What is the first action the nurse should take? A. Place a coolrag on the client's head B. Suction the client's oral cavity C. Provide the client an emesis basin D. Place the client in a side-laying position D. Place the client in a side-laying position The nurse is caring for a 10-year-old child with hemophiliawho hasrecently been diagnosed asHIV positive. What precautions should the nurst take when interacting with the child and mother? A. No special precautions are needed B. Wear gloves only C. Wear gloves and a mask D. Wear a mask, gloves and gown. A.No special precautions are needed 40 A 26 year-old primigravida who delivered a7-poundmale infant 26 hours ago tells the nurse thatshe is confused about when she and her husband can return to having sexual intercourse. What info should the nurse reinforce with this client? A. They can have intercourse when the episiotomy is healed and the lochial flow hasstopped B. They should waitto resume sexualactivities untilthe fatigue assorted with a new baby has passed C. They can resume sexualactivity at 6 weeks postpartum D. It is besttowait until both parties feelup to having sexualintercourse A. They can have intercourse when the episiotomyis healed and the lochial flow has stopped The healthcare provider tells the family of a 6-year old child with a malignant brain tumor that the tumoris metastasizing and the child's condition is terminal.How can the nurse best help the family cope with this news? A. Referthe family to a support group to find answersto theirquestions B. Reinforce the stages ofthe grieving process C. Listen to the family'sreactions and reflect and their fears and concerns D. Transferthe child to a private room C. Listen to the family's reactions and reflect and theirfears and concerns The nurse is implementing the plan of 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. Describes being very depressed B. Has little appetite and neglects personalhygiene C. Is not interested in the activities of family and friends D. Beginsto show signs of improvement D. Beginsto show signs of improvement On a short-staffed unit a long-termcare facility, it is importantthatthe nurse assign the unlicensed assistive personnel (UAP) to complete morning care for the resident with which problem first? 41 A. Dyspneawho uses oxygen continously B. Straight catheterization to be performed q6h C. Frequent episidoes of fecalincontinence D. Bolusfeeding viaPEG tube to be performed q4h C. Frequent episidoes of fecalincontinence The nurse assess a client receiving a hypertonic fullstrength tube feeding thatisinfusing continous at 50 mL/hr. Which finding is most important for the nurse to reprot to the charge nurse? A. Dry mucousmembranes B. Gastric residualof 50 mL C. Report of increased hunger D. Hyperactive bowelsounds C. Report of increased hunger A male client who was admitted with Gangrene ofthe rightlowerextremity (RLE) is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the nurse take next? A. Explain the consequences of Sepsisifthe amputation is delayed B. Notify the RNthatthe client's wife needsfurther explanation aboutthe procedure C. Document on the client'srecord the refusalforsurgical treatment D. Enourage the client's wife to express concerns aboutmaking the decision D. Enourage the client's wife to express concerns aboutmaking the decision A male client attends a community support program for mentally impaired and chemically abusive clients. The client tellsthe nurse that his drug of choice are cocaine and heroin. What is the greatest health risk for this client? 42 A. Hepatitis B. Hypertention C. Diabetes D. Glaucoma D. Glaucoma A male client who was admitted with Gangrene ofthe rightlowerextremity (RLE) is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the nurse take next? A. Explain the consequences of Sepsisifthe amputation is delayed B. Notify the RNthatthe client's wife needsfurther explanation aboutthe procedure C. Document on the clientrecord the refusalforsurgical treatement D. Encourage the client's wife to express concerns aboutmaking the decision D. Encourage the client's wife to express concerns aboutmaking the decision The nurse is caring for a group of clients on a postpartumunit. Aftershiftreport, which client should the nurse assess first? A. Gravida 6 Para 5 who delivered vaginally 24 hours ago B. Gravida 1 Para 0 who is not having contractions C. Gravida 3 Para3 who delivered vaginally 2 hours ago D. Gravide 1 Para 2 who is preparing fordischarge C.Gravida 3 Para 3 who delivereed vaginally 2hours ago A clientreturnsto the unit following a cardiac catheterization with a Femoralartery Access. Which objective criteria is most important for the nurse to obtain immediately upon the clients return? A. Pupil responsesto light B. Pedalpulses 43 C. Respiratory rate D. Peripheralmobility B. Pedalpulses An elderly female clienttells the nurse thatshe does not do regularBreast Self Examinations(BSE) because she is too old. The nurse's response to the client is based on what information? A. The incidence of breast cancerincreases with age B. The client should have a health care providerdo a breast examatleast once a year C. After age 70, breast canceris less likely to occur D. The history of breast cancerin a family memberisindicative ofthe need forBSE A. The incidence of breast cancerincreases with age A clientwith Meningitisis in a coma and Nursing care includesseizure precautions. To help prevent seizure activity, what interventions should the nurse implement? A. Maintain an oral airway suction equpment and oxygen atthe bedside B. Provide respiratory isolation precautionsfor visitors and staff C. Provide emergencyanticonvulsantmedication atthe bedside D. Maintain a quiet calm darkened enviornment D. Maintain a quiet calm darkened enviornment The nurse is assisting a female clientto obtain a voided specimen forurine culture. Afterthe client cleanses the meatus, which intervention is performed next? A. Initiate the urine stream B. Seperate the labia C. Position the collection cup D. Observe the urine B. Seperate the labia 44 A new protocolforfall prevention is being implemented on the medicalunit.During safety rounds,the nurse identifies that an unlicensed assistive personel (UAP) has omitted a vital component of the protocol. After implementing the missing component, what should action should the nurse take? A. Reportthe UAP's omission to the charge nurse B. Complete an unusualoccurence report C. Supervise the UAP afterreviewing the protocol D. Assign the UAP tomore stable clientsthe next day C. Supervise the UAP afterreviewing the protocol What is the bestintervention forthe nurse to implementwhen providingmorning care for an ambulatory client with an indwelling catheter (Foley)? A. Keep the catheterintactwhile assisting the client with a shower B. Remove the catheterwhile the clienttakes a shower C. Provide the clientwith a sponge bath in a chair or the bed D. Assistthe client with a tub with the catheter clamped A. Keep the catheterintactwhile assisting the client with a shower Based on the Nursing diagnosis of, "Risk forInfection," which intervention should the nurse implement when providing care for an elderly client with Urinary incontinence? A. Maintain standard precautions B. Utilize an antibacterial perinealwash C. Insert an indwelling urinary catheter D. Initiate contact isolation precautions A. Maintain standard precautions 45 The charge nurse brings a #18fr urinary catheter (Foley) with a 30 mL balloon to the nurse who is preparing to insert a catheterin a female clientwho weighs 50 kg.What action should the nurse take first? A. Ask the client ifshe has previously been catheterized B. Position the client and observe the urinarymeatus C. Obtain a 30 mlsyringe and a vial of sterile water D. Consultwith the chage nurse aboutthe catheter D. Consultwith the chage nurse aboutthe catheter An 82-year old client is admitted to the hospital with a fractured right hip. Following surgical repair, a footboard is placed at the client's feet. What is the reason the nurse will offer concerning the footboard? The footboard is used to... A. Preventfoot drop B. Prevent hip dislocation C. Promote moving in bed D. Promote early ambulation A. Preventfoot drop Following a leftleg above the knee amputation (AKA), a client voicesseveral complaints. Which statement should be reported to the charge nurse immediately? A. My leftfootis so painful B. My incision is so dry C. I've been feeling so light headed D. I'm tired ofturning so much C. I've been feeling so light headed In caring for a client following a below the knee amputation (BKA)which task is bestfor the nurse to delegate to the unlicensed assistive personnel (UAP) who is assisting with the care of this client? 46 A. Empty andmeasure the drainage in the suction drainage device B. Reassure the clientthat phantomlimb pain is genuine pain C. Review the client's vitalsigns forindications of infection D. Observe andmark the amount of drainage on the dressing A. Empty and measure the drainage in the suction drainage device 2 days after an abdominal hysterectomy, an elderly client with diabetes Mellitus Type II has a syncopal episode. Her vitalsigns are within normal limites and hersugar is 325 mg/dL. what intervention should the nurse implement first? A. Give the client 4 ounces of orange juice B. Administernextscheduled dose of metformin (Glucophage) C. Cancelthe clients dinnertray D. Administerregularinsulin persliding scale D. Administerregularinsulin persliding scale A client returns to the postoperative unit following an open reduction and internal fixation of a hip fracture. The practical nurse appliesthe prescribed sequential compression devise(SCD) to bo