HESI EXIT EXAM HESI EXIT EXAM

HESI EXIT EXAM HESI EXIT EXAM HESI EXIT EXAM A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? A. Allow client to use the bedpan B. Explain the fetal head is descending C. Perform a sterile vaginal exam D. Assist the client to the bathroom C. Perform a sterile vaginal exam 2 The nurse assesses a 78 y.o. male client who has left sided heart failure. Which symptoms would the nurse expect this client to exhibit? A. Dyspnea, cough, fatigue B. Hepatomegaly and distended neck veins C. Pain over pericardium and friction rub D. Narrowing pulse pressure and distant heart sounds A. Dyspnea, cough, fatigue 3 A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for a 22 y.o. son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior anymore since all she does is care for their son. What intervention should the nurse implement? A. Teach the client to problem solve for herself and establish her own priorities B. Schedule a home visit in the afternoon to assess the son and client's role as caregiver C. Provide feedback to the client about her atonement for guilt and her son's impairment D. Acknowledge the client's stress and suggest that she consider respite care D. Acknowledge the client's stress and suggest that she consider respite care 4 The nurse plans to administer a scheduled dose of Toprol at 0900 to a client with HTN. At 0800 the nurse notes the the client's telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take? A. Administer the Toprol immediately and monitor the client carefully until the heart rate increases B. Provide the dose of Toprol as scheduled and assign a UAP to monitor the client's BP every 30 min C. Hold the scheduled dose of Toprol and notify HCP of the telemetry pattern D. Give the Toprol as scheduled if the client's systolic blood pressure reading is greater than 180 C. Hold the scheduled dose of Toprol and notify HCP of the telemetry pattern 5 A client who developed Syndrome of Inappropriate Antidiuretic Hormone (SIADH) associated with small cell carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline, the nurse should instruct the client to report which condition to the HCP? A. Anxiety B. Insomnia C. Muscle cramping D. Increased appetite C. Muscle cramping 6 In determining the client position for insertion of an indwelling catheter, it is most important for the nurse to recognize which client condition? A. High urinary pH B. Fever C. Abdominal ascites D. Orthopnea D. Orthopnea 7 The nurse is reviewing a client's EKG and determines the PR interval is prolonged. What does this finding indicate? A. Inability of SA node to initiate an impulse at normal rate B. Initiation of the impulse from a location outside the SA node C. Increased conduction time from the SA node to the AV junction D. Interference with the conduction through one or both ventricles C. Increased conduction time from the SA node to the AV junction 8 The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the crede method. When performing a return demonstration, the client applies pressure to the umbilical area of his abdomen. What instruction should the nurse provide? A. Stroke the inner thigh below the perineum to initiate urinary flow B. Pour warm water over the external sphincter at the distal glans C. Apply downward manual pressure at the suprapubic region D. Contract, hold, and then relax the pubococcygeal muscle C. Apply downward manual pressure at the suprapubic region 9 A 35 y.o. female client has just been admitted to the postanesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery? A. Supplemental hormonal therapy will probably be unnecessary B. The thyroid will regenerate to a normal size within a few years C. The client will be restricted from eating seafood D. The remainder of the thyroid will be removed at a later date B. The thyroid will regenerate to a normal size within a few years 10 A client with gestational diabetes, at 39 weeks gestation is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? A. Lower the head of the bed and apply suprapubic pressure B. Encourage the client to move to a hands and knees position C. Prepare the client for an emergency cesarean birth D. Assist the client to sharply flex her thighs up against the abdomen D. Assist the client to sharply flex her thighs up against the abdomen 11 The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic? A. Rapid onset of action B. Low bioavailability C. Narrow therapeutic index D. Short half-life C. Narrow therapeutic index 12 Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective? A. Decreased abdominal girth B. Increased blood pressure C. Clear breath sounds D. Decreased serum albumin A. Decreased abdominal girth 13 When finding a client sitting on the floor, the nurse calls for help from the UAP. Which task should the nurse ask the UAP to do? A. Check for any abrasions or bruises B. Help the client to stand C. Get a blood pressure cuff D. Report the fall to the nurse-manager C. Get a blood pressure cuff 14 During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement? A. Notify the pediatrician immediately B. Teach the parents about cogenital heart defects C. Document the finding in the infant's record D. Apply oxygen per nasal cannula at 3 L/min C. Document the finding in the infant's record 15 A client is diagnosed with a frontal lobe glioma, which is a benign brain tumor. When teaching the client about the tumor, which information should the nurse consider? A. Surgery is not indicated unless the tumor becomes malignant B. Vision and hearing will be affected in the future C. If the tumor metastasizeds surgical intervention is likely D. Personality changes or expressive aphasia are likely D. Personality changes or expressive aphasia are likely 16 A client who has suffered 3rd degree burns over 60% of the body is admitted to the emergency department. The HCP writes a prescription for IV Lactated Ringers at 350 ml/hr. Which intervention should the nurse implement? A. Administer the Lactated Ringers at 350 ml/hr via gravity infusion B. Collaborate with the pharmacist to recalculate the infusion rate C. Obtain an intravenous infusion pump prior to administering the IV D. Call the HCP and question the prescription C. Obtain an intravenous infusion pump prior to administering the IV 17 A male client with HIV who is being admitted to a healthcare facility, tells the nurse that he is concerned about his right to have access to his records and explanations regarding his treatment and the cost. Which resource should guide the nurse's response to this client? A. The Patient's Bill of Rights B. The hospital policy and procedure manual C. The Nurse Practice Act D. The client's Durable Power of Attorney A. The Patient's Bill of Rights 18 When assessing the oral temperature of an adult client at 6:00pm, the nurse notes that the client's temperature at 6:00am was 97.2 and now is 98.8. Which intervention should the nurse take? A. Document this intermittent fever in the nurse's notes B. Administer a PRN dose of mediation to reduce fever C. Document this temperature variate on the graphic sheet D. Notify the HCP of the increase in temp C. Document this temperature variate on the graphic sheet 19 It would be of greatest benefit for the client with which problem related to diabetes mellitus to change from the use of insulin syringes to using an insulin pen for medication administration? A. Lipodystrophy from continuous use of one injection site B. Hyperglycemia due to noncompliance with diet C. Diminshed dexterity due to finger paresthesias D. Blindness secondary to diabetic retinopathy C. Diminshed dexterity due to finger paresthesias 20 A one y.o. child with neuroblastoma is cry continuously and is curled into a fetal position. What action is most important for the nurse to implement? A. Give the prescribed analgesic B. Reduce light and noise in the room C. Offer the child a favorite toy to clutch D. Ask the parent to rock the child A. Give the prescribed analgesic 21 A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit. Which instruction should the nurse provide to the client's family? A. Keep the client busy during the weekend B. Instruct the family to administer all client medications C. Limit the number of visitors that come to the home D. Involve the client in usual at-home activities D. Involve the client in usual at-home activities 22 The nurse is evaluating an asthmatic client's response to an inhaled corticosteroid medication. what assessment finding indicates the medication has been effective in controlling the asthma symptoms? The client has increased A. Peak flow meter rates B. Retraction of chest muscles C. Volume of expiratory wheezes D. Viscosity of tracheal secretions A. Peak flow meter rates 23 In reviewing the goals of "Healthy People" the nurse determines that the community has a significant problem in preventing dental caries among children. To bring about change that addresses this identified community health problem, where is the best place to initiate a prevention program? A. WIC program intake offices B. Pediatricians' offices in clinics C. Social security office D. Dentist's offices int he community A. WIC program intake offices 24 In planning care for a client with a nursing diagnosis of "Impaired mobility" the nurse instructs the UAP to assist the client with ambulation. Because the HCP has prescribed bed rest for the client, what action should the nurse take? A. Update the plan of care to include ambulatory assistance by the nurse rather than UAP B. Instruct the UAP to provide sufficient assistance to ensure client safety during ambulation C. Revise the prescribed medical treatment plan to include frequent ambulation with assistance D. Change the planned interventions to include range of motion exercises rather than ambulation D. Change the planned interventions to include range of motion exercises rather than ambulation 25 When assigning a UP to assist a client with personal care, which client information is most important for the nurse to provide the UAP? A. The client's weight B. IV site location C. Turning schedule D. Prescribed activity level D. Prescribed activity level 26 Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech, bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse identifies a nursing diagnosis of, "Altered thought processes, secondary to" what condition? A. Postpartum psychosis B. Postpartum depression C. Paranoid personality D. Adjustment disorder A. Postpartum psychosis 27 The nurse is preparing to discharge a client from the hospital who has aphasia secondary to a CVA. What instruction should the nurse provide the family to assist them in communicating with the client? A. Provide ongoing stimulation for the client such as a radio turned on in the room B. Speak much slower and louder to help client with comprehension C. Be consistent in using the same words each time a question is asked D. Give detailed explanations before assisting the client with any care C. Be consistent in using the same words each time a question is asked 28 The intensive care department is full and short staffed, so the nursing supervisor informs the charge nurse int he medical department that one nurse must float to the ICU. Which nurse should the medical department charge nurse send to the intensive care department? A. A staff nurse who was sent to work in the intensive care department yesterday B. A nurse who has been working the medical floor since graduation one year ago C. A nurse who has recently transferred from the emergency room to the medical floor D. A staff nurse who was cross-trained to work in the critical care department D. A staff nurse who was cross-trained to work in the critical care department 29 A mother brings her newborn infant to the well-baby clinic for the one month check-up. The nurse reviews the infant's records and identifies that the newborn received the first dose of HBV immunization upon discharge from the nursery. When should the nurse recommend the administration of the next booster for the HBV series? A. At the next clinic visit or 3 months of age B. During this visit, one month of age C. The last two doses should be administered at 11-12 years of age D. At 6 months of age B. During this visit, one month of age 30 When assessing a restless intubated client who is on a mechanical ventilator, the nurse auscultates breath sounds on the right side of the chest only. What action should the nurse implement next? A. Provide comfort and sedation for the client B. Mark the lipline on the tube with indelible ink C. Apply soft wrist restraints per protocol D. Reposition the depth of the endotracheal tube D. Reposition the depth of the endotracheal tube 31 A male client taking several medications complains of sexual dysfunction. The nurse knows that this is a side effect commonly associated with which of his current mediations? A. Mylanta B. Theophylline C. Ampicillin D. Vasotec D. Vasotec 32 The parents of two children with sickle cell disease ask the nurse to explain why both of their children have this disease. Which concept should the nurse use to provide an explanation? A. The chances of two children in a family not having the sickle cell disease is 50% B. Each child has a 25% chance of inheriting the sickle cell trait from both parents C. All of your children will be carriers of the sickle cell trait D. Children of parents with the trait will manifest the disease B. Each child has a 25% chance of inheriting the sickle cell trait from both parents 33 A client with a cervical spinal cord injury is brought to the emergency center. What should be the nurse's priority assessment? A. Obtain injury and health history B. Check blood pressure C. Assess the respiratory pattern D. Assess ability to move extremities C. Assess the respiratory pattern 34 A 13 y.o. female client is evaluated at a mental health clinic because her parents suspect she is using an illicit substance. Symptoms reported to HCP include sleep disturbances, slurred speech, mild hand tremors, and trouble hearing. Based on these symptoms, the nurse should screen for which stance? A. Ecstasy B. Crack cocaine C. Marijuana D. Paint thinner D. Paint thinner 35 The charge nurse is developing the nursing guidelines for a coronary care unit. Which reference is likely to be the most useful in developing these guidelines? A. The American Heart Association's recommendations on diet and lifestyle B. The Patient's Bill of Rights C. The Scope of Standards of Practice from American Nurses' Association D. The Americans with Disability Act C. The Scope of Standards of Practice from American Nurses' Association 36 A male client who is in the day room becomes increasingly angry and aggressive when he is denied a day-pass. Which action should the nurse implement? A. Instruct the client to sit and be quiet B. Decrease the volume on the TV set C. Tell him he can have a day pass if he calms down D. Put the client's behavior on extinction B. Decrease the volume on the TV set 37 The nurse is assessing a client following a thoracotomy and left lung pneumonectomy. What assessment finding should the nurse anticipate? A. Absent breath sounds on left side of chest B. Decreased breath sounds on the left, clear breath sounds on the right C. Diminished breath sounds auscultated bilaterally D. Crackles and wheezes auscultated in the right lung fields A. Absent breath sounds on left side of chest 38 A male client with Type 1 diabetes mellitus takes a combination of short-acting and intermediate acting insulin drugs. The client complains of headaches when awakening and his blood glucose average for the past week has been 210. The nurse recognizes the client is experiencing a daily Somogyi or rebound effect. Which dosing method is likely to relieve these symptoms? A. Increase the short-acting dose before lunchtime B. Move the PM intermediate-acting dose to bedtime C. Delay the morning doses until after breakfast D. Increase the intermediate-acting dose with evening meal B. Move the PM intermediate-acting dose to bedtime 39 When obtaining a throat culture from a 5 y.o. with possible streptococcal infection, which action is most important for the nurse to implement? A. Instruct the child to look at the ceiling and open mouth widely B. Allow the child to hold the tongue depressor and practice saying "Ah" C. Encourage the parent to hold the child during the procedure D. Swab the child's erthematous oropharyngeal surfaces or tonsilar pustules D. Swab the child's erthematous oropharyngeal surfaces or tonsilar pustules 40 The nurse is caring for a 42 y.o. male client who is excreting less sodium than he is consuming. If this condition continues, what complication can the nurse expect this client to exhibit? A. Hyponatremia B. Edema C. Dehydration D. Azotemia B. Edema 41 Which condition would likely cause polycythemia? A. Acute blood loss B. Graft versus host disease C. Hereditary spherocytosis D. High altitude exposure D. High altitude exposure 42 An infant is treated for intussusception with hydrostatic reduction. What instruction should the nurse include in the parent's teaching plan? A. Skills needed for care of a stoma B. Steps in tube feeding administration C. Low fat, high-protein diet D. Signs and symptoms of recurrence D. Signs and symptoms of recurrence 43 The nurse is planning care for a 48 y.o. client, diagnosed with schizophrenia at age 25, who has been taking antipsychotic drugs since diagnosis. Long-term use of these drugs is associated with which side effect? A. Dystonia B. Akathisia C. Tardive dyskinesia D .Parkinsonism C. Tardive dyskinesia 44 What instruction is most important for the nurse to provide a client with neutrophilia? A. Avoid sources of potential infection B. Take precautions to minimize bleeding C. Schedule regular rest periods D. Avoid exposure to excessive ultraviolet light A. Avoid sources of potential infection 45 A client with acute laryngitis reports feeling SOB. The nurse assesses that the client's respiratory rate has increased from 16/min to 28/min. What intervention should the nurse implement? A. Assess the client for stridor and increased respiratory effort B. Administer an IV anagesic per PRN protocol C. Provide written means of ocmmunication for the client D. Determine the client's recent exposure to irritating substances A. Assess the client for stridor and increased respiratory effort 46 When caring for a client who had a craniotomy yesterday for removal of a pituitary tumor, which finding indicates to the nurse that further information is needed? A. WBC are 11,000 and glucose is 138 B. Suture line is slightly reddened and swollen C. Urine output for 8 hours is 2,000 with specific gravity of 1.001 D. Glasgow coma scale is 14 C. Urine output for 8 hours is 2,000 with specific gravity of 1.001 47 The nurse is working with an interdisciplinary group to write procedures for assessment of clients from a multiracial inner city population. The guidelines include a statement that reads, "Remember that all Hispanic clients may not wish to give personal medical information to a stranger." Which action should the nurse take? A. Conclude that this guideline is written in a culturally sensitive context B. Suggest that the client assessment address this ethnicity group C. Revise the guideline to include a checklist that provides a racial profile D. Recommend changing the language that stereotypes one ethnic group D. Recommend changing the language that stereotypes one ethnic group 48 What nursing action has the highest priority in preventing postoperative bleeding following a submucosal resection for a deviated septum? A. Reinforce pressure-dressing PRN B. Provide mouth care hourly C. Maintain intact nasal packing D. Instruct client to expectorate secretions C. Maintain intact nasal packing 49 A female client chooses to have a prophylactic mastectomy because she has a positive BRCA1 mutation, her mother died of breast cancer at age 30, and her cousin was diagnosed with breast cancer at 28. Which intervention is most critical for the nurse to include int his client's immediate postoperative plan of care? A. Review information about available reconstruction choices B. Determine the client's understanding of the risk for ovarian cancer C. Ensure adequate pain control using postoperative analgesics D. Assess the client's emotional reaction to prophylactic surgery C. Ensure adequate pain control using postoperative analgesics 50 The psychiatric nurse is called to a train derailment that was likely caused by a terrorist bomb. In triaging those in need of immediate care, what is the prioritiy ranking for these cases? (Arrange these cases in order of priority with top item requiring most immediate care) 1 - Woman sitting on the groud with a blanket wrapped 2 - A middle aged man who is wandering around the scene 3 - A mother and father have just arrived on the scene looking 4 - A crying child being held by another passenger 1 - A middle aged man who is wandering around the scene 2 - Woman sitting on the groud with a blanket wrapped 3 - A crying child being held by another passenger 4 - A mother and father have just arrived on the scene looking 51 A client with pneumonia is admitted with severe SOB and ABG of: pH = 7.3, PaO2 = 60, pCO2 = 62, HCO3 = 25. Which information should the nurse communicate immediately to the HCP? A. Occasional premature ventricular contactions B. Drowsiness and difficulty in arousing C. Heart rate of 115 bpm D. Complaint of a headache B. Drowsiness and difficulty in arousing 52 The nurse is teaching a primigravida who describes herself as a lacto-vegetarian about nutrition during pregnancy. Which foods should the nurse encourage this client to include in her diet? A. Cheese, green salads and fruit B. Chicken, milk and green vegetables C. Eggs, milk, and green salads D. Fish, brown rice and ruits A. Cheese, green salads and fruit 53 The number of a 5 y.o. boy calls the emergency room and reports that a pot of hot soup was pulled off the stove onto her child's right arm and leg. What should the nurse tell this mother to do first? A. Put him on a warm surface until an ambulance can arrive B. Place him in a cool bath and remove his clothing C. Wrap the child in a blanket and bring him to the hospital immediately D. Immobilize him by rapping him tightly in a clean sheet C. Wrap the child in a blanket and bring him to the hospital immediately 54 A nurse is caring for a client with diagnosis of acute renal failure who complains of SOB, weakness, headache and swelling of lower legs and feet. What nursing intervention should be completed immediately? A. Administer PRN Motrin B. Elevate HOB at least 45 degrees C. Percuss abdomen to check for ascites D. Encourage client to deep breath and cough C. Percuss abdomen to check for ascites 55 A client with acute low back pain reports pain radiating down the buttock to below the knee. Initial nursing actions should be based on what interpretation of these symptoms? A. Ischemic pain is occurring due to arterial compression B. The client is describing classic signs of phantom pain C. This pain is along the path of the sciatic nerve D. The client is experiencing severe muscle strain and spasm C. This pain is along the path of the sciatic nerve 56 The nurse is attempting to teach a male client newly diagnosed with diabetes how to administer insulin. When the nurse attempts to answer the client's questions he becomes angry and tells the nurse that the entire process is just too much to learn. What action is best for the nurse to take? A. Encourage the family to learn how to administer the insulin until the client is able to handle the procedure B. Ignore the client's outbursts and continue with the instructions C. Acknowledge the client's feelings and tell him that he will eventually be able to do self-administration D. Explain to the client that he cannot go home until he learns to administer the insulin C. Acknowledge the client's feelings and tell him that he will eventually be able to do self-administration 57 In evaluating the effectiveness of a client's nocturnal sleep patterns, what information is best for the nurse to obtain? A. The number of times the client voids during the night B. Recall of experiencing dreaming during the night C. The number of hours the client sleeps each night D. Self-evaluation of feeling well rested upon awakening D. Self-evaluation of feeling well rested upon awakening 58 Four clients present to the labor and delivery unit at the same time. The nurse should asses the client with which complaint first? A. Has not felt baby for the last 12 hours B. Contractions every 10 minutes C. Urinary frequency and burning with urination D. Abdominal pain and bright red bleeding D. Abdominal pain and bright red bleeding 59 The nurse is conducting discharge teaching about the antianxiety drug Valium. Which instruction has the highest priority for inclusion in the teaching plan? A. If muscle spasms occur during treatment, notify the HCP B. Crush tablets and take with food or water if difficult to swallow C. Notify HCP if anxiety to continues two weeks after start of treatment D. Evaluate the ingredients of all the OTC meds for alcohol content D. Evaluate the ingredients of all the OTC meds for alcohol content 60 A male Muslim client with pneumonia is scheduled to receive a dose of IV antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to ender his body once he is cleansed for prayer. Which action should the nurse implement? A. Reschedule administration of the antibiotic until he completes his prayers B. Instruct the client that the antibiotics must be given on time to be effective C. Ask the pharmacist to supply an oral form of the antibiotic for the client D. Notify the HCP that the client has refused the scheduled antibiotic A. Reschedule administration of the antibiotic until he completes his prayers 61 After administering a medication through an NG tube connected to suction, what action should the nurse take first? A. Clamp the tube B. Reconnect the tube to suction C. Document medication administration D. Discard supplies used B. Reconnect the tube to suction 62 Which of these women, all of whom have recently discovered a breast lump is at greater risk of breast cancer? A. A 51 y.o. who mother had breast cancer and describes lump as non-tender B. A 22 y.o. who has firocystic breast-disease and describes the lump as painful C. A 45 y.o. who is taking estrogen therapy and has had 4 children since age of 28 D. A 55 y.o. whose weight is normal for her height and had on child at age 31 A. A 51 y.o. who mother had breast cancer and describes lump as non-tender 63 Which client situation requires the most immediate intervention by the nurse? A. A stage 2 pressure ulcer located on the client's sacrum and is draining a moderate amount of purulent drainage B. A stage 4 pressure ulcer that has a 5 cm area of necrosis surrounded by pale pink tissue C. A 4 cm area of dehiscence is observed on a client's abdominal incision one day after surgery D. A 6 cm area of reactive hyperemia is observed over the left trochanter of a bedfast client C. A 4 cm area of dehiscence is observed on a client's abdominal incision one day after surgery 64 On admission, the HCP prescribes a broad-spectrum antibiotic, ticarcillin, for the client with a gram-negative infection. Before administering the first dose, it is important for the nurse to implement which prescription? A. Irrigation and topical antibiotic to the wound area B. Wound and blood specimens for C&S C. Monitor for signs of sodium and fluid retention D. Complete blood and serum electrolyes B. Wound and blood specimens for C&S 65 The nurse observes that a client receiving an aminoglycoside for an infection appears dizzy when ambulating. The nurse should consult with the HCP regarding the need for which test? A. Peak and trough B. Creatinine clearance C. Culture and sensitivity D. White blood count A. Peak and trough 66 The nurse is administering a continuous IV infusion of dopamine (Inotropin) to a client. Which assessment finding indicates that the therapeutic effect has been achieved? A. Clear breath sounds B. Decrease in central venous pressure C. Conversion to normal sinus rhythm D. Increased blood pressure D. Increased blood pressure 67 The wife of a client with terminal cancer gives the nurse a copy of her husband's living will. What action should the nurse take? A. Alert the nursing staff of a client's DNR status B. Place a certified copy of the living will in the client's chart C. Notify the HCP of the client's wishes D. Facilitate a family meeting with the palliative care team C. Notify the HCP of the client's wishes 68 A client with a fractured femur is placed in traction to immobilize the fracture. When transporting this client to another room, how should the nurse handle the traction? A. Prevent movement of the weights by resting them on top of the bed until arrival B. Increase the amount of weights by 50% during transport C. Release the weight during transport and reconnect on arrival D. Leave the weights in place for the full duration of the transport D. Leave the weights in place for the full duration of the transport 69 The HCP prescribed triazolam (Halcion) 500 mcg for a client with insomnia. The pharmacy supplies Halcion 0.35 mcg tablets. How many tablets should thenurse administer? 2 70 A client who is being prepared for discharge following a transurethral resection of the prostate (TURP) tells the nurse that he is concerned about being constipated. Which instruction should the nurse give this patient? A. Use glycerin rectal suppositories as needed B. Use oral stool softeners daily C. Use a soft-tip mineral oil enema as needed D. Take a laxative of choice daily B. Use oral stool softeners daily 71 A 3 y.o. child visits the clinic with both parents for a well-child check up. The nurse auscultates bronchovesicular breath sounds in the peripheral lung fields and assesses the child's respiratory rate of 28 breaths/minute. Which interpretation of this finding is accurate? A. An expected finding B. Tachypnea C. Asthmatic wheeze D. Mucus plug in bronchus A. An expected finding 72 The nurse is providing preoperative teaching to a female client scheduled for surgery tomorrow at an ambulatory surgery center. Which instruction is most important for the nurse to include? A. Teach the client how to describe her pain using a numeric scale B. Advise the client to make arrangements for someone to drive her home C. Instruct the client not to bring any valuable jewelry to the surgery center D. Explain to the client that an IV line will be started before surgery A. Teach the client how to describe her pain using a numeric scale 73 In performing an inital assessment of an infant with cryptorchidism, the nurse should also asses for which finding? A. Abnormal bowel sounds and closed fontanels B. A heart murmur and poor weight gain C. Difficulty feeding and a history of frequent emesis D. A reducible or non-reducible bulging in the inguinal area D. A reducible or non-reducible bulging in the inguinal area 74 A Up reports to the nurse that a postop client is complaining of abdominal pain and has a respiratory rate of 32 breaths per minute. What action should the nurse implement? A. Use the numeric pain scale to determine the client's pain level B. Tell the UAP to retake the client's vital signs in thirty minutes C. Assist the client with the use of an incentive spirometer D. Administer a PRN prescription for oxygen per nasal canula A. Use the numeric pain scale to determine the client's pain level 75 A 4 y.o. boy is admitted to the hospital for a urinary tract infection. Which statement made by the mother warrants further exploration by the nurse? A. He is so active, I'm encouraging him to rest at home B. I think it's best to discuss his problem outside the room C. He really likes to play with the children's doll house D. Review the client's record for evidence of birth trauma B. I think it's best to discuss his problem outside the room 76 While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding spurts rather than trickles from the vagina. The uterine fundus is firm and the client's V/S are: 104/68 88-21. What action should the nurse take next? A. Initiate an hourly perineal pad count B. Compare current vital signs with previous vital signs C. Place the infant at the mother's breast D. Review the client's record for evidence of birth trauma B. Compare current vital signs with previous vital signs 77 An infant who weighs 22 pounds is receiving an IV solution of 96 ml/kg/24 hours. The nurse the program the pump to deliver how many ml/hr? 40 78 The nurse determines that an IV infusion in a client's right forearm is a stage 4 infiltration. After removing the IV catheter, what action should the nurse take? A. Evaluate the color and temperature of the right hand B. Auscultate the client's breath sounds bilaterally C. Assess range of motion in the client's right arm D. Measure the client's blood pressure in the left arm A. Evaluate the color and temperature of the right hand 79 In assessing a female client with Type 2 diabetes mellitus, the nurse notes that the client has gained five pounds since her last clinic visit 6 months ago. The client reports that she has been following her diet and that her glucose levels are under control. What indicator best reflections the client's control of her diabetes? A. A fasting blood glucose level B. Client report s/sx hyperglycemia C. A glycosylated hemoglobin level D. A 24 hour urinalysis for ketone bodies C. A glycosylated hemoglobin level 80 The nurse tests a client's visual acuity and determines that the uncorrected vision is 20/100 in the right eye and 20/80 in the left eye. What does this finding indicate? A. The left eye is the dominant eye B. Difficulty seeing things at close range C. Difficulty seeing at a distance D. Difficulty visualizing objects at a distance D. Difficulty visualizing objects at a distance 81 A client with a permanent pacemaker develops loss of capture resulting in symptomatic sinus bradycardia at a rate of 38 breaths/min. Which IV medication should the nurse prepare to administer immediately? A. Atropine B. Amiodarone C. Adenosine D. Atenolol A. Atropine 82 A 25 y.o. female client reports to the nurse that she has a throbbing headache over her left eye that began early yesterday right after experiencing dark spots in her vision. Movement makes her nauseous, but lying still in a dark room does provide some relief. OTC pain medications have not helped. This client is describing what type of headache? A. Classic migraine B. Temporal arthritis C. Sinus headache D. Cluster headache A. Classic migraine 83 A client is admitted to the emergency room because of an overdose of Tylenol. Following gastric lavage, the nurse should expect to administer what medication? A. Haldol B. Procardia C. Valium D. Mucomyst D. Mucomyst 84 A client with hyperparathyroidism reports increasing lethargy and seems confused. It is most important for the nurse to obtain which serum lab test results? A. Potassium B. Calcium C. White blood count D. Hemoglobin and hematocrit B. Calcium 85 The charge nurse is assessing the morning lab work on four clients. Which client's laboratory findings should prompt the charge nurse to contact the HCP immediately? A. A 74 y.o. diagnosed with COPD who has ABG's: pH = 7.35, PCO2 = 49 HCO2 = 26 B. A 50 y.o. diagnosed with myocardial infarction who has an elevated CPK-MB on serial cardiac enzymes C. A 35 y.o. diagnosed with pneumonia having a white blood count of 13,000 D. A 29 y.o. diagnosed with ulcerative colitis have a serum potassium of 3.1 D. A 29 y.o. diagnosed with ulcerative colitis have a serum potassium of 3.1 86 The nurse is assessing an adult who displays stagnation, boredom and interpersonal impoverishment. Based on erikson's developmental model, which stage should the nurse develop interventions for this client A. Generativity v. stagnation B. Identity v. role confusion C. Intimacy v. isolation D. integrity v. despair A. Generativity v. stagnation 87 The nurse obtains lying and standing BP's for a female client who complains of dizziness every time she stands up fromt the computer at work. The nurse determines that her SBP decreases 24 points when she stands. What intervention is most important for the nurse to implement? A. Determine if the client takes antihypertensive medications B. Encourage the client to flex her feet before rising slowly C. Review the client's history for an incidence of syncope D. Recommend that the client drink plenty of water every day B. Encourage the client to flex her feet before rising slowly 88 A client is receiving lidocaine IV at 3 mg/minute. The pharmacy dispences a 500 ml IV solution with 2 grams of lidocaine. The nurse should regulate the infusion pump at how many ml/hr? 45 89 A school age child with asthma is intubated and placed on a mechanical vent. The parents of the child are pale, holding onto each other and have tears in their eyes. What statement by the nurse is most therapeutic when first interacting with these parents? A. The ventilator is making sure your child is getting enough oxygen B. It must be difficult for you to see your child go through this C. Your child is in good hands. Everything is going to be okay D. Your child is resting comfortably at the present time B. It must be difficult for you to see your child go through this 90 The nurse is conducting a community education program on osteoporosis prevention. Which physical activity would be best to recommend to women 65 years of age and older for prevention of osteoporosis? A. Brisk walking for 2 hours over a period of a week B. Aerobic dancing one hour a day, five days per week C. Swimming 45 minutes a day, three times per week D. Stretching exercises for 20 minutes three times per week A. Brisk walking for 2 hours over a period of a week 91 A client admitted to the nursing unit with a possible bowel obstruction. The nurse auscultates high-pitched bowel sounds in the upper quadrants of the client's abdomen. What is the significance of this finding? A. Indicates beginning resolution of the obstruction B. Reflects the probability of impending peritonitis C. Provides data about the location of the obstruction D. Determines accurate placement of the NG tube C. Provides data about the location of the obstruction 92 Which statement by a client would cause the nurse to suspect that the client may be experiencing an MI? A. I have a burning pain in my chest when I lay down B. My chest hurts when I walked up the stairs C. I have chest pain when I take a deep breath D. It seems like a vise is squeezing my chest D. It seems like a vise is squeezing my chest 93 The nurse is administering an IM injection and performs the Z-track technique. At what point should the nurse release the tissue that is retracted laterally during the injection? A. After performing aspiration to detect vessel entry B. After the insertion of the needle into the muscle mass C. After injection of the medication into the muscle mass D. After the needle is withdrawn from the skin surface D. After the needle is withdrawn from the skin surface 94 The nurse is caring for a 5 y.o. with Reye's syndrome. What goal has the highest priority in caring for this child? A. Prevent long-term complication and cardiac damage B. Control hypotension and shock C. Reduce cerebral edema and lower intracranial pressure D. Promote oral fluid intake and prevent kidney damage C. Reduce cerebral edema and lower intracranial pressure 95 An adult male who admits to abusing IV drugs obtains results of HIV test. When informed that the results are positive, he states that he does not want his wife to know. What action should the nurse take? A. Tell the client he is required by law to inform his sexual partners of his HIV status B. Counsel the client about the importance of notifying his sexual partner C. Inform the wife of her health risk related to her husbands HIV results D. Report the client's results as a sexually transmitted case to the health department B. Counsel the client about the importance of notifying his sexual partner 96 When bathing an elderly client, the nurse notes the client's skin is very dry, flaky and rough. Which nursing intervention should be added to this client's plan of care? A. Provide alcohol-based lotions to prevent cracking B. Decrease bath to every other day using non-irritating soap C. Apply protective ointment containing zinc oxide to posterior side D. Use antimicrobial soaps to reduce infection risk B. Decrease bath to every other day using non-irritating soap 97 A male client was admitted to the intensive care unit three days ago following a motor vehicle collision and is today being discharged to the medical unit. One hour before discharge, his blood pressure is 160/110 and his pulse is 120 beats per minute. He tells the nurse, "I feel like my skin is crawling" Which value is most important for the nurse to assess? A. Admission alcohol level B. Hemoglobin and hematocrit C. Serum amylase D. White blood count A. Admission alcohol level 98 A male client with hypertension has begun to exhibit signs of diabetic retinopathy. To help decrease the retinopathy, the nurse should encourage the client to try and become more diligent in managing which situation? A. Taking anti-hypertensive drugs as directed B. Seeing an opthalmologist every 6 months C. Maintaining better control of blood sugar levels D. Avoiding large crowds to reduce infections C. Maintaining better control of blood sugar levels 99 The wife of a terminally ill client is concerned because her husband insists on talking about past events. Which response is best for the nurse to provide? A. Encourage the wife to provide current information to her husband B. Support the wife by listening attentively to her complaints C. Notify the hospital chaplain of the wife's concern D. Explain that reminiscing about one's life is common among the dying D. Explain that reminiscing about one's life is common among the dying 100 The nurse is caring for a toddler who has a medical diagnosis of coarctation of the aorta. Which assessment finding should the nurse report to the HCP immediately? A. Blood pressure higher in upper extremities B. Weak femoral pulses C. Pulse oximeter reading of 94% D. Crackles at end of inspiration D. Crackles at end of inspiration 101 A client's case is being reviewed by the hospital's multi-disciplinary ethics committee. What information could the nurse provide to the committee regarding this case? A. Descriptions of client behavior during the hospitalization that indicate ineffective coping B. Information about treatment alternatives that offer the greatest chance of recovery C. Counsel on how to legally document the client's wishes to have the living will enacted D. Advice about handling a spiritual conflict a client may experience as a result of an ethical crisis A. Descriptions of client behavior during the hospitalization that indicate ineffective coping 102 A 16 y.o. female client who attempted suicide that morning is admitted to the psychiatric unit. To determine seriousness of the adolescents suicide attempt, which question is most important for the nurse to ask the family? A. Has anything occurred which might have precipitated this attempt B. How did she attempt to kill herself C. How long has she seemed depressed D. Has she ever attempted to commit suicide before? B. How did she attempt to kill herself 103 A high school football player comes to the clinic complaining of severe acne. The mother reports recent behavior changes including irritability and suspiciousness of friends. The nurses's assessment reveals an elevated blood pressure. Which intervention should the nurse implement first? A. Suggest a low salt, low fat, caffeine-free diet B. Encourage the client to see a dermatologist C. Refer the adolescent to a substance abuse program D. Inquire about use of anabolic steroids D. Inquire about use of anabolic steroids 104 In caring for a client with a fracture of the femur, the nurse should be alert for compartment syndrome. what symptom is characteristic of this complication? A. Acute anxiety, diaphoresis, elevated blood pressure B. Positive homan's signs with calf tenderness and warmth C. Deep throbbing unrelenting pain not controlled with opioids D. Tachycardia and petechiae over the chest wall and buccal membrands C. Deep throbbing unrelenting pain not controlled with opioids 105 A child is admitted to the hospital with diarrhea and vomiting. Potassium chloride is prescribed for inclusion with rehydration IV fluids. Prior to administering the potassium, the nurse should ensure which condition exists A. The oxygen saturation level per pulse ox is 95% B. The client is able to void assuring kidney function is present C. The client has stopped vomiting before potassium is added to the IV fluids D. The client has had no cardiac arrhythmias B. The client is able to void assuring kidney function is present 106 A client whose blood type is A, Rh negative is scheduled to receive a unit of blood. Two nurses verify the blood type and proceed with the transfusion. One of these nurses should stop the administration of the blood based on what data? A. One nurse stays for 15 minutes after the initiation of the transfusion B. The blood bag label tag and requisition slip state Rh negative C. The collection of vital signs every hour is delegated to the UAP D. The nurse identifies the client by checking the room number D. The nurse identifies the client by checking the room number 107 The nurse has not finished administering routine oral medication because one client experienced chest pain and another rectal bleeding. It is now dinnertime and two clients must be fed. The UAP is filling water pitchers, and the PN is charting V/S. Which change in assignments is best for the team leader to make? A. UAP monitor client with rectal bleeding, PN feed two clients and RN finish oral medications and monitor client with chest pain B. UAP feed two clients, PN monitor clients with chest pain and rectal bleeding, RN finish oral medications C. UAP record V/S, PN feed two clients, RN finish oral medications and monitor clients with chest pain and rectal bleeding D. Up feed two clients, PN finish oral medications, and RN monitor clients with chest pain and rectal bleeding D. Up feed two clients, PN finish oral medications, and RN monitor clients with chest pain and rectal bleeding 108 A postop client has developed evisceration. Which nursing diagnosis should be added to the client's plan of care? A. Altered breathing patterns B. Bow incontinence C. Fluid volume deficit D. Impaired skin integrity D. Impaired skin integrity 109 The nurse is caring for a male client who suffered a right CVA resulting in left-sided hemiparesis. Which observation of the client indicates that he is experiencing homonymous hemianopsia? A. Complains of ringing in the ears B. States the bright lights bother him C. Eyes are reddened and inflamed D. Neglecting the left side of his body D. Neglecting the left side of his body 110 While completing the admission assessment of a client at 24 weeks gestation who is contracting every 5 minutes, the nurse notes several bruises on her abdomen. The client reports that the bruises are a result of her boyfriend kicking her in the stomach. what order should the nurse implement the nursing actions? 1 - Administer prescribed tocolytic 2 - Take pictures of the abdominal bruising 3 - Document fetal heart rate 4 - Notify the police of the assault 1 - Document fetal heart rate 2 - Administer prescribed tocolytic 3 - Take pictures of the abdominal bruising 4 - Notify the police of the assault 111 Following a transient ischemic attack during which a male client experienced hemiparesis, he asks the nurse if he had a "stroke." What is the best response by the nurse? A. This type of attack is very different from and not related to a stroke B. This type of stroke is usually temporary and has few residual facts C. You experience a stroke caused by lack of oxygen to your brain D. This attack is not a stroke but indicates you're at risk for a stroked D. This attack is not a stroke but indicates you're at risk for a stroked 112 A male client returns to the acute care unit following surgery with sequential compression devices in place. The nurse observes that the client dorsiflexes his feet frequently. What action should the nurse implement? A. Encourage the client to perform foot exercises regularly while is mobility is limited B. Offer to massage the client's feet and legs while assisting him with personal care C. Remove the SCD's while the client exercises his feet D. Advise the client to avoid flexing his feet while wearing the SCD's A. Encourage the client to perform foot exercises regularly while is mobility is limited 113 A HCP orders Stadol 1 mg and Phergan 12. mg IM for a 38 week primigravida who is in early labor. Stadol is available in 2 mg/1ml vials and Phergan is available in 50 mg/1ml ampules. The nurse plans to administer the drugs in one injection. How many ml should the injection contain? 0.75 114 A client who is immunocompromised because of treatment for systemic lupus erthematosus delievers a viable infant at 37 weeks gestation by c-section. Four days later she has a fever of 102.6F and diarrhea. A stool speicimen is positive for C-Diff. What action should the nurse take? A. Do not allow visitors until the diarrhea has stopped B. Remove the infant from the mother's room C. Place the client in enteric isolation D. Put the mother and infant in separate isolation rooms C. Place the client in enteric isolation 115 Which statement by a client indicates to the nurse that the client understands how a newly prescribed transdermal medication will be administered? A. The medicine is injected in the tissue just below the skin laye B. I will place the medicine directly under my tongue C. The medicine will be applied directly on my skin D. The needle is injected just barely under my skin C. The medicine will be applied directly on my skin 116 Prior to administering digoxin two nurses assess the heart rate of a client with atrial fibrillation. The both obtain an apical pulse rate of 96 beats/minute and radial pulse of 77 beats/minute. Calculate the client's pulse deficit. 19 117 A client diagnosed with a DVT is followed by a diagnosis of pulmonary embolism is receiving heparin via an infusion pump at a rate of 1400 U/her. The client tells the nurse, " I wish this medicine would hurry up and dissolve the clot in my lungs so I can go home." What response is best for the nurse to provide? A. You seem to be concerned about the length of time it takes for heparin to dissolve the clot B. Why are you so anxious to leave the hospital when you know you are not well enough yet C. Let me contact your surgeon and find out if heparin IV therapy can be given to you at home D. Heparin prevents future blood clot formation but your risk of bleeding needs to be closely monitored D. Heparin prevents future blood clot formation but your risk of bleeding needs to be closely monitored 118 A male translator is working with the nurse who is giving discharge instructions to a non-English speaking client. When the translator restates what the nurse is saying, it appears that he is saying much more than what the nurse said. what action should the nurse take? A. Remind the translator that his role is to only restate what the nurse says B. Say nothing to the translator since he is licensed to explain the instructions C. Ask the translator if there is a reason for the lengthiness of the translation D. Request another translator to verify the accuracy of the translations C. Ask the translator if there is a reason for the lengthiness of the translation 119 A nurse is named as a defendant in a malpractice case. What action should the nurse take? A. Purchase additional professional liability insurance B. Talk to the client and apologize for the harm suffered C. Discuss the client's claim with other nurses to gain their support as witnesses D. Contact the nurse's professional liability insurance company D. Contact the nurse's professional liability insurance company 120 A female client admitted to a long-term care facility appears to be confused and frightened. She offers her belongings including valuable jewelry, to members of the nursing staff if they promise to stay with her and not leave her alone. What action should the nurse implement? A. Accept the client's jewelry as a gift and assign a staff member to remain with the client B. Encourage the staff to pretend to accept gifts until the client feels secure at the facility C. Make an inventory of the belongings and send the valuables home with a family member D. Remove the client's valuables and place them in the client's drawer out of sign of visitors C. Make an inventory of the belongings and send the valuables home with a family member 121 The nurse is teaching a childbirth education class to prospective parents and describing possible signs of labor. Class participants should be taught that which sign should be reported to the HCP immediately? A. Contractions occurring 10-15 min apart B. Passing of excessive mucous from the vagina C. Leaking of fluid from the vagina D. Lower back pain and urinary frequency C. Leaking of fluid from the vagina 122 The nurse performs a series of heel sticks to obtain glucose levels on a large for gestational age newborn. Because the glucose was 48 on admission and 39 one hour later, a venous specimen for laboratory analysis of serum glucose concentration is obtained. What action is most important for the nurse to implement? A. Place a cap on the infant to prevent heat loss B. Provide an external heat source to prevent shivering C. Notify the HCP D. Take the newborn to the mother to be breast fed D. Take the newborn to the mother to be breast fed 123 A home healthcare agency set the goal: "Use informatics as a method for improving healthcare delivery. What nursing action is directed toward achieving this goal? A. Use a standardized worksheet to organize assigned daily client care B. Document client care using an interdisciplinary problem-oriented record C. Enter accurate client data into client's computerized medical records D. Encourage clients and families to help develop the client's plan of care C. Enter accurate client data into client's computerized medical records 124 A female client with Type 1 diabetes is trying to lose weight and recently started exercise program. Which information is most important for the nurse to provide this client? A. Increase carbohydrate intake before exercising B. Take insulin before exercising C. Drink water while exercising D. Wear shoes that are well-fitted and white socks A. Increase carbohydrate intake before exercising 125 During the second treatment with IV antibiotic, the client develops a rash on the upper torso. What intervention should the nurse implement first? A. Document the finding in the client's record B. Take the client's blood pressure C. Notify the HCP D. Observe the client's breathing pattern D. Observe the client's breathing pattern 126 A male client with moderate Alzheimers disease had abdominal surgery yesterday. Today, when the nurse performs a dressing change, the client states, "I don't want you to change my dressing." What is the best initial action for the nurse to take? A. Explain the importance of dressing change and proceed with the procedure B. Ask another nurse who has cared for the client to do the dressing change C. Leave the room and re-approach the client in 30 minutes D. Do not change the dressing and note "refused" in the client's record C. Leave the room and re-approach the client in 30 minutes 127 The nurse is preparing a teaching plan for a 23 y.o. female client who has had a kidney transplant. What should be the nurse's focus in conducting this teaching? A. Describing the necessity of eating high purine foods and avoiding foods high in calcium and oxalate B. Stressing the importance of life-long medical follow-up care after the kidney transplant C. Outlining the signs of rejection which include increase in urinary output and weight loss D. Explaining that the immunosupressant medications must be decreased gradually when being discontinued B. Stressing the importance of life-long medical follow-up care after the kidney transplant 128 What instruction should the nurse include in the discharge teaching of a client with ulcerative colitis who has had a traditional ileostomy A. Instruct the client to empty ostomy once daily B. Tell client to call HCP if ostomy becomes purple C. Explain that a high fiber diet should be followed for the first 6-8 weeks after ileostomy D. Demonstrate and provide written instructions on how to irrigate the ostomy B. Tell client to call HCP if ostomy becomes purple 129 The community health is planning a nutritional program that targets older adults who live alone and who may be in need of additional community services. Which intervention should the nurse implement first? A. Develop an evaluation plan that focuses on the effectivness of the program B. Gather information about the makeup of the population using a windshield survey C. Prepare visual aids, handouts and food samples for participants D. Post announcements at the community center about upcoming topics B. Gather information about the makeup of the population using a windshield survey 130 A family member contacts the nurse at the client mental health center and wishes to share concerns and asks questions about a client's medications. What action is best for the nurse to take? A. Obtain written consent from the client to talk to the family member about treatment B. Determine if the client knows that the family member is requesting info C. Make a note in the chart about what was disclosed during the interaction D. Ask the family member to explain how the nursing staff can be most helpfu A. Obtain written consent from the client to talk to the family member about treatment 131 A family member brings a basket of fresh fruit to a client with decreased neutrophil count due to chemotherapy. What action should the nurse take? A. Encourage the client to eat the fruit as a small health snack B. Remove any fruit that provides high fiber C. Encourage the client to eat the fruits high in vitamin C D. Remove all of the fruit from the client's room D. Remove all of the fruit from the client's room 132 A male client has a potassium level of 5.9 and tells the nurse that he has decided to leave the hospital even without discharge orders and is refusing all treatments. It is most important for the nurse to make sure he understands which fact? A. He must be informed that insurance will not pay for visit if he leaves AMA B. He must sign the AMA form making him responsible for consequences of not having care C. He can return to the hospital for treatment if he changes his mind D. He must understand that his condition is serious and he could die as a result of leaving AMA D. He must understand that his condition is serious and he could die as a result of leaving AMA 133 A 6 y.o. boy was hit with a bat and has a splinter of wood embedded in his eye. What action should the school nurse take? A. Rinse eye and remove object B. Remove object and patch eye C. Call parent and send child home D. Have parent take child to ED D. Have parent take child to ED 134 What is the rationale for the nurse teaching a client to compress the lacrimal duct with eye medications? A. To prevent systemic absorption B. To reduce pain C. To prevent irritation D. To reduce eye "tearing" A. To prevent systemic absorption 135 3 days after surgery a client who had a laryngectomy has elevated pulse and respiratory rate. His skin is dry and he is thrashing in bed. What intervention should the nurse do first? A. Apply restraints B. Suction C. Administer PRN sedative D. Call HCP B. Suction 136 A client with chronic kidney disease has hemodialysis on Mondays and Wednesdays. What action should the nurse implement on Wednesday morning? A. Hold lisinopril morning dose B. Keep patient NPO before hemodialysis C. Notify HCP of lab results D. Give PRN novolog A. Hold lisinopril morning dose 137 A client returned to the nursing unit after surgery and has pulse of 120, restlessness, cyanosis, gurgles on expiration and inspiration. What action should the nurse take first? A. Perform oropharyngeal suction B. Report findings to HCP C. Administer oxygen via rebreather D. Bring intubation supplies A. Perform oropharyngeal suction 138 In shift report the nurse is told of several problems. Which problem should the nurse address first? A. A bucket of water spilled in the hallway B. Client's wife wants to speak to charge nurse C. Census report has not been completed D. Staff member has not reported to work A. A bucket of water spilled in the hallway 139 The nurse plans to administer IV heparin bolus of 80/kg to client weighing 210 pounds. How many units should be administered? 7636 140 The nurse administers NPH to a child at 7:30am. When should the insulin be most effective in lowering blood sugar A> Late evening to bedtime B. Before lunchtime C. During night D. Mid-afternoon to dinnertime D. Mid-afternoon to dinnertime 141 The nurse is beginning the process of changing the central venous catheter dressing of a client receiving total parenteral nutrition. After applying sterile gloves, what action should the nurse take? A. Cleanse site B. Remove original dressing C. Secure transparent dressing D. Apply facemask A. Cleanse site 142 A nurse manager is preparing an annual budget for the unit. Nursing salaries should be included in which component of the budget? A. Budget variance B. Operating budget C. Capital budget D. Cost containment B. Operating budget 143 A middle aged female client is admitted to the hospital with a medical diagnosis of acute renal failure. The HCP informs her that her treatment will include hemodialysis. Which response demonstrates that this client understands what will occur with hemodialysis? A. Dialysis will not interfere with my job at all. I am off on weekends so I will just do the dialysis then B. Using the kidney machine every few days will help rest my kidneys so they can function again C. I don't understand how this could have happened to me. No one in my family has ever had to be on dialysis before D. Our children were coming for a visit over Christmas. Now we will have to cancel our holiday plans B. Using the kidney machine every few days will help rest my kidneys so they can function again 144 The nurse is assigning rooms for four clients, each newly