HESI_chemistry.docx entrance exam

Hesi Final Exam Version 3 Hesi Final Exam Version 3 1. 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 the client to use a bedpan. B. Explain the fetal head is descending. C. Perform a sterile vaginal exam. D. Assist the client to the bathroom. 2. The nurse assesses a 78-year-old male client who has left sided heart failure. Which symptoms would the nurse expect this client to exhibit? A. Dyspnea, cough and fatigue. B. Hepatomegaly and distended neck veins. C. Pain over the pericardium and friction rub. D. Narrowing pulse pressure and distant heart sounds. 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-year-old 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 about her son’s impairment. D. Acknowledge the client’s stress and suggest that she consider respite care. 4. The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that 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 q30 minutes. C. Hold the scheduled dose of Toprol and notify the healthcare provider of the telemetry pattern. D. Give the Toprol as scheduled if the client’s systolic blood pressure reading is greater than 180. 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 (Declomycin), the nurse should instruct the client to report which condition to the healthcare provider? A. Anxiety. B. Insomnia. C. Muscle cramping. D. Increased appetite. 6. In determining the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition? A. High urinary pH. B. Fever. C. Abdominal ascites. D. Orthopnea. 7. The nurse is reviewing a client’s electrocardiogram and determines that the PR interval (PRI) is prolonged. What does this finding indicate? A. Inability of the SA node to initiate an impulse at the 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. 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. A 35-year-old 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. 9. 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. 10. 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. 11. 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. 12. When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (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. 13. 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 congenital heart defects. C. Document the finding in the infant’s record. D. Apply oxygen per nasal cannula at 3 L/min. 14. 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 metastasizes, surgical intervention is necessary. D. Personality changes or expressive aphasia are likely. 15. A client who has suffered 3rd degree burns over 60% of the body is admitted to the emergency department. The healthcare provider writes a prescription for “IV Lactated Ringer’s 350 ml/hr”. Which intervention should the nurse implement? A. Administer the Lactated Ringer’s 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 healthcare provider and question the prescription. 16. 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 of such treatment. 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. 17. When assessing the oral temperature of an adult client at 6:00 pm, the nurse notes that the client’s temperature at 6:00 am was 97.2, and is now 98.8. Which intervention should the nurse implement? A. Document this intermittent fever in the nurse’s notes. B. Administer a PRN dose of medication to reduce the fever. C. Document this temperature variation on the graphic sheet. D. Notify the healthcare provider of the increase in temperature. 18. 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. Diminished dexterity due to finger paresthesias. D. Blindness secondary to diabetic retinopathy. 19. A one-year-old child with neuroblastoma is crying continuously and is curled into a fetal position. What action is most important for the nurse to implement? A. Give a 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. 20. 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 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. 21. The nurse is evaluating an asthmatic client’s response to an inhaled corticosteroid medication. What assessment finding indicates that the medication has been effective in controlling the asthma symptoms? The client has increased A. Peak flow meter rates. B. Retraction of the chest muscles. C. Volume of expiratory wheezes. D. Viscosity of tracheal secretions. 22. 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. Dentists’ offices in the community. 23. In planning care for a client with a nursing diagnosis of “Impaired mobility”, the nurse instructs the unlicensed assistive personnel (UAP) to assist the client with ambulation. Because the healthcare provider 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 the 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. 24. When assigning an unlicensed assistive personnel (UAP) 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. 25. 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. 26. The nurse is preparing to discharge a client from the hospital who has aphasia secondary to a cerebrovascular accident (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 the 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. 27. The intensive care department is full and short staffed, so the nursing supervisor informs the charge nurse in the 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. 28. 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 the HBV immunization upon discharge from the newborn 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. 29. 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 lip line on the tube with indelible ink. C. Apply soft wrist restraints per protocol. D. Reposition the depth of the endotracheal tube. 30. 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 medications? A. Aluminum hydroxide (Mylanta). B. Theophylline (Theo-dur). C. Ampicillin (Omnipen). D. Enalapril maleate (Vasotec). 31. 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. 32. 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 the blood pressure. C. Assess the respiratory pattern. D. Assess ability to move extremities. 33. A 13-year-old female client is evaluated at a mental health clinic because her parents suspect she is using an illicit substance. Symptoms reported to healthcare provider include sleep disturbances, slurred speech, mild hand tremors, and trouble hearing. Based on these symptoms, the nurse should screen for which substance? A. Ecstasy. B. Crack cocaine. C. Marijuana. D. Paint thinner. 34. 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 of 1990. C. The Scope of Standards of Practice from the American Nurses’ Association. D. The Americans with Disability Act of 1990. 35. 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 down and be quiet. B. Decrease the volume on the television set. C. Tell him he can have a day pass if he calms down. D. Put the client’s behavior on extinction. 36. 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 the left side of the 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. 37. 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 mg/dl. 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. 38. When obtaining a throat culture from a 6-year-old 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 the 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 erythematous oropharyngeal surfaces or tonsilar pustules. 39. The nurse is caring for a 42-year-old 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. 40. Which condition would likely cause secondary polycythemia? A. Acute blood loss. B. Graft versus host disease. C. Hereditary spherocytosis. D. High altitude exposure. 41. An infant is treated for intussusception with hydrostatic reduction. What instruction should the nurse include in the parents’ 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. 42. The nurse is planning care for a 48-year-old 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. 43. What instruction is most important for the nurse to provide a client with neutropenia? A. Avoid sources of potential infection. B. Take precautions to minimize bleeding. C. Schedule regular rest periods. D. Avoid exposure to excessive ultraviolet light. 44. A client with acute laryngitis reports feeling “short of breath”. The nurse assesses that the client’s respiratory rate has increased from 16/minute to 28/minute. What intervention should the nurse implement? A. Assess the client for stridor and increased respiratory effort. B. Administer an intravenous analgesic per PRN protocol. C. Provide written means of communication for the client. D. Determine the client’s recent exposure to irritating substances. 45. 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. White blood cells (WBC) are 11,000/mm and glucose is 138 mg/dl. B. Suture line is slightly reddened and swollen. C. Urine output for 8 hours is 2,000 ml with a specific gravity of 1.001. D. Glasgow come scale (GCS) score is 14. 46. 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. 47. 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. 48. 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 age 28. Which intervention is most critical for the nurse to include in this 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. 49. 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 priority ranking for these cases? (Arrange these cases in order of priority, with the top item requiring the most immediate care and the bottom item requiring the least priority care.) 4 - A mother and father have just arrived on the scene looking 2 - A woman sitting on the ground with a blanket wrapped 3 - A crying child being held by another passenger, who is 1 - A middle-aged man who is wandering around the scene 50. A client with pneumonia is admitted with severe shortness of breath and arterial blood gases of pH 7.30, PaO2 60 mm Hg, PaCO2 62 mm Hg, HCO2 35 mEq/liter. Which information should the nurse communicate immediately to the healthcare provider? A. Occasional premature ventricular contractions. B. Drowsiness and difficulty in arousing. C. Heart rate of 115 beats/minute. D. Complaint of a headache. 51. 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 fruits. 52. The mother of a 5-year-old 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 wrapping him tightly in a clean sheet. 53. A nurse is caring for a client with a diagnosis of acute renal failure who complains of shortness of breath, weakness, headache, and swelling of the lower legs and feet. What nursing intervention should be completed immediately? A. Administer PRN dose of ibuprofen (Motrin). B. Elevate the head of the bed at least 45 degrees. C. Percuss abdomen to check for ascites. D. Encourage the client to deep breathe and cough. 54. A client with acute low back pain reports pain radiating down the buttock to below the knee. Initial nursing actions should be based on which 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. 55. 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 better 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. 56. 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. 57. Four clients present to the Labor and Delivery unit at the same time. The nurse should assess the client with which complaint first? A. Has not felt the baby for the last 12 hours. B. Contractions every 10 minutes. C. Urinary frequency and burning on urination. D. Abdominal pain and bright red bleeding. 58. The nurse is conducting discharge teaching about the antianxiety drug diazepam (Valium). Which instruction has the highest priority for inclusion in the teaching plan? A. If muscle spasms occur during treatment, notify the healthcare provider immediately. B. Crush tablets and take with food or water if they are difficult to swallow. C. Notify the healthcare provider if anxiety continues two weeks after beginning treatment. D. Evaluate the ingredients of all over-the-counter drugs for alcohol content. 59. A male Muslin client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. Which action should the nurse implement? A. Reschedule administration of the antibiotic until after 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 healthcare provider that the client has refused the scheduled antibiotic. 60. After administering a medication through a nasogastric tube connected to suction, what action should the nurse take first? A. Clamp the tube. B. Re-connect the tube to the suction. C. Document the medication administration. D. Discard the supplies used. 61. Which of these women, all of whom have recently discovered a new breast lump, is at greatest risk for a diagnosis of breast cancer? A. A 51-year-old whose mother had breast cancer and describes the lump as non-tender. B. A 22-year-old who has fibrocystic breast-disease and describes the lump as painful. C. A 45-year-old who is taking estrogen therapy and has had four children before the age of 28. D. A 55-year-old whose weight is normal for her height, and had one child at age 31. 62. Which client situation requires the most immediate intervention by the nurse? A. A stage II pressure ulcer located on the client’s sacrum is draining a moderate amount of purulent drainage. B. A stage IV pressure ulcer has a five-centimeter area of necrosis surrounded by pale pink tissue. C. A four-centimeter area of dehiscence is observed on a client’s abdominal incision one day after surgery. D. A six-centimeter area of reactive hyperemia is observed over the left trochanter of a bedfast client. 63. On admission, the healthcare provider prescribes a broad-spectrum antibiotic, ticarcillin (Ticar), for a 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 application to wound area. B. Wound and blood specimens for culture and sensitivity. C. Monitor for signs of sodium and fluid retention. D. Complete blood and serum electrolytes. 64. The nurse observes that a client receiving an aminoglycoside for an infection appears dizzy when ambulating. The nurse should consult with the healthcare provider regarding the need for which test? A. Peak and trough. B. Creatinine clearance. C. Culture and sensitivity. D. White blood cell count. 65. The nurse is administering a continuous IV infusion of dopamine (Intropin) to a client. Which assessment finding indicates that the therapeutic effect has been achieved? A. Clear breath sounds bilaterally. B. Decrease in central venous pressure. C. Conversion to normal sinus rhythm. D. Increased blood pressure. 66. 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 do not resuscitate status. B. Place a certified copy of the living will in the client’s chart. C. Notify the healthcare provider of the client’s wishes. D. Facilitate a family meeting with the palliative care team. 67. 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 the transport. C. Release the weight during transport and reconnect them upon arrival. D. Leave the weights in place for the full duration of the transport. 68. The healthcare provider prescribed triazolam (Halcion) 500 mcg for a client with insomnia. The pharmacy supplies Halcion in 0.25 mg tablets. How many tablets should the nurse administer? (Enter numeric value only.) 2 69. A client who is being prepared for discharge following a transurethral resection of the prostate (TURP) tells the nurse that he is concerned about becoming constipated. Which instruction should the nurse provide to this client? 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. 70. A 3-year-old 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 the bronchus. 71. 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 pain 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 intravenous line will be started before surgery. 72. In performing an initial assessment of an infant with cryptorchidism the nurse should also assess 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. 73. An unlicensed assistive personnel (UAP) reports to the nurse that a postoperative client is complaining of abdominal pain and has a respiratory rate of 32 breaths per minute. What action should the nurse implement? A. Use a 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 cannula. 74. A 4-year-old 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 some.” 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. “I am so sorry, but he really asks a lot of questions.” 75. 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 vital signs are: pulse, 88 beats/minute; respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg. 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. 76. An infant who weighs 22 pounds is receiving an IV solution at 96 ml/kg/24 hours. The nurse should program the infusion pump to deliver how many ml/hour? 40 77. The nurse determines that an intravenous infusion in a client’s right forearm is a stage 4 infiltration. After removing the intravenous 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 the range of motion of the client’s right arm. D. Measure the client’s blood pressure in the left arm. 78. 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 six months ago. The client reports that she has been following her diet and that her glucose levels are under control. What indicator best reflects the client’s control of her diabetes? A. A fasting blood glucose level. B. Client report of symptoms of hyperglycemia. C. A glycosylated hemoglobin level. D. A 24-hour urinalysis for ketone bodies. 79. 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 objects at close range. C. Difficulty seeing at any distance. D. Difficulty visualizing objects at a distance. 80. Identify the location of the pinnae that the nurse should pull upward and outward while instilling eardrops into an adult’s ear. 81. A client with a permanent pacemaker develops loss of capture resulting in symptomatic sinus bradycardia at a rate of 38/minute. Which intravenous medication should the nurse prepare to administer immediately? A. Atropine sulfate (Atropine). B. Amiodarone (Cordarone). C. Adenosine (Adenocard). D. Atenolol (Tenormin). 82. A 25-year-old 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. Over-the-counter pain medications have not helped. This client is describing which type of headache? A. Classic migraine. B. Temporal arthritis. C. Sinus headache. D. Cluster headache. 83. A client is admitted to the emergency room because of an overdose of acetaminophen (Tylenol). Following gastric lavage, the nurse should expect to administer which medication? A. Haloperidol (Haldol). B. Nifedipine (Procardia). C. Diazepam (Valium). D. Acetylcysteine (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 cell count. D. Hemoglobin and hematocrit. 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 healthcare provider immediately? A. A 74-year-old diagnosed with COPD who has ABGs of pH 7.35, PaCO2 49, PaO2 74, HCO2 26. B. A 50-year-old diagnosed with myocardial infarction who has an elevated CPK-MB on serial cardiac isoenzymes. C. A 35-year-old diagnosed with pneumonia having a white blood cell (WBC) of 13,000 mm. D. A 29-year-old diagnosed with ulcerative colitis having a serum potassium level of 3.1 mEq/L. 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 versus stagnation. B. Identity versus role confusion. C. Intimacy versus isolation. D. Integrity versus despair. 87. The nurse obtains lying and standing blood pressure measurements for a female client who complains of dizziness every time she stands up from the computer at work. The nurse determines that her systolic pressure decreases 24 mmHg 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 any incidence of syncope. D. Recommend that the client drink plenty of water every day. 88. A client is receiving lidocaine IV at 3 mg/minute. The pharmacy dispenses a 500 ml IV solution of normal saline (NS) with 2 grams of lidocaine. The nurse should regulate the infusion pump to deliver how many ml/hr? 45 89. A school-age child with asthma is intubated and placed on a mechanical ventilator. 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.” 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. 91. A client is 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. Documents accurate placement of the nasogastric tube. 92. Which statement by a client would cause the nurse to suspect that the client may be experiencing a myocardial infarction? A. “I have a burning pain in my chest when I lie 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.” 93. The nurse is administering an intramuscular 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. 94. The nurse is caring for a 5-year-old 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 septic shock. C. Reduce cerebral edema and lower intracranial pressure. D. Promote oral fluid intake and prevent kidney damage. 95. An adult male who admits to abusing IV drugs obtains the results of HIV testing. 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 husband’s HIV results. D. Report the client’s results as a sexually transmitted case to the health department. 96. When bathing an elderly client, the nurse notes that 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. 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/minute. He tells the nurse, “I feel like my skin is crawling.” Which lab value is most important for the nurse to assess? A. Admission alcohol level. B. Hemoglobin and hematocrit. C. Serum amylase. D. White Blood Count (WBC). 98. A male client with diabetes and 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 ophthalmologist every 6 months. C. Maintaining better control of blood sugar levels. D. Avoiding large crowds to reduce infections. 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. 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 healthcare provider immediately? A. Blood pressure higher in upper extremities. B. Weak femoral pulses. C. Pulse oximeter reading of 94%. D. Crackles at the 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. 102. A 16-year-old female client who attempted suicide that morning is admitted to the psychiatric unit. To determine the seriousness of the adolescent’s suicide attempt, which question is most important for the nurse to ask the family? A. “Has anything occurred which might have precipitated this suicide attempt?” B. “How did she attempt to kill herself?” C. “How long has she seemed depressed?” D. “Has she ever attempted suicide before?” 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 nurse’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 possible 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, and elevated blood pressure. B. Positive Homan’s sign with calf tenderness and warmth. C. Deep, throbbing, unrelenting pain which is not controlled with opioids. D. Tachycardia and petechiae over the chest wall and buccal membranes. 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 that which condition exists? A. The oxygen saturation level per pulse oximeter is greater than 95%. B. The client is able to void, assuring kidney function is present C. The client has stopped vomiting before the potassium is added to the IV fluids. D. The client has had no cardiac arrhythmias in the last 24 hours. 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 which data? A. One nurse stays for 15 min. 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 an UAP. 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 not dinnertime and two clients must be fed. The unlicensed assistive personnel (UAP) is filling water pitchers, and the practical nurse (PN) is charting vital signs. Which change in assignments is best for the team leader to make? A. UAP monitor client with rectal bleeding, PN feed the two clients, and RN finish oral medications and monitor the client with chest pain. B. UAP feed the two clients, PN monitor clients with chest pain and rectal bleeding, RN finish oral medications. C. UAP record vital signs, PN feed two clients, RN finish oral medications and monitor clients with chest pain and rectal bleeding. D. UAP feed the two clients, PN finish oral medications, and RN monitor clients with chest pain and rectal bleeding. 108. A postoperative client has developed an evisceration. Which nursing diagnosis should be added to the client’s plan of care? A. Altered breathing patterns. B. Bowel incontinence. C. Fluid volume deficit. D. Impaired skin integrity. 109. The nurse is caring for a male client who suffered a right cerebrovascular accident (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. 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. In what order should the nurse implement these nursing actions? 3 - Take pictures of the abdominal bruising. 4 - Notify the police of the assault. 2 - Administer the prescribed tocolytic. 1 - Document the fetal heart rate. 111. Following a transient ischemic attack (TIA) 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 effects.” C. “You experience a stroke caused by lack of oxygen to your brain.” D. “This attack is not a stroke, but indicates you are at risk for a stroke.” 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 his mobility is limited. B. Offer to massage the client’s feet and legs while assisting him with personal care. C. Remove the sequential compression devices while the client exercises his feet. D. Advise the client to avoid flexing his feet while wearing the compression device. 113. A healthcare provider prescribes butorphanol (Stadol) 1 mg and promethazine (Phenergan) 12.5 mg IM for a 38-week primigravida who is in early labor. Stadol is available in 2 mg/l ml vials and Phenergan is available 50 mg/I ml ampules. The nurse plans to administer both drugs in one injection. How many ml should the injection contain? 0.75 114. A client who is immunosuppressed because of treatment for systemic lupus erythematosus (SLE) delivers a viable infant at 37-weeks gestation by cesarean section. Four days later she has a fever of 102.6 F and diarrhea. A stool specimen is positive for Clostridium difficile. 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. 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 layer.” 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.” 116. Prior to administering digoxin (Lanoxin), two nurses assess the heart rate of a client with atrial fibrillation. They 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 deep vein thrombus (DVT), followed by a diagnosis of pulmonary embolism (PE), is receiving heparin via an infusion pump at a rate of 1400 U/hr. The client tells the nurse, “I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home.” What response is best for the nurse to provide? A. “You seem to be concerned about the length of time is takes for Heparin to dissolve this 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 monitored closely.” 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 he 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. 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 (plaintiff) 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. 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 and 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 sight of visitors. 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 healthcare provider immediately? A. Contractions occurring 10 to 15 minutes apart. B. Passing of excessive mucous from the vagina. C. Leaking of fluid from the vagina. D. Lower back pain and urinary frequency. 122. The nurse performs a series of heel sticks to obtain glucose levels on a large-for-gestational age (LGA) newborn. Because the glucose was 48 mg/dl on admission and 39 mg/dl 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 healthcare provider. D. Take the newborn to the mother to breastfeed. 123. A home health care agency set the goal: “Use informatics as a method for improving health care 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 clients’ computerized medical records. D. Encourage clients and families to help develop the client’s plan of care. 124. A female client with Type 1 diabetes mellitus is trying to lose weight, and recently started an 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. 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 healthcare provider. D. Observe the client’s breathing pattern. 126. A male client with moderate Alzheimer’s disease had abdominal surgery yesterday. Today, when the nurse begins to perform 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 before to do the dressing change. C. Leave the room and re-approach the client in about 30 minutes. D. Do not change the dressing and note “refused” in the client’s medical record. 127. The nurse is preparing a teaching plan for a 23-year-old 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 immunosuppressant medications must be decreased gradually when being discontinued. 128. What instruction should the nurse include in the discharge-teaching plan of a client with ulcerative colitis who has had a traditional ileostomy? A. Instruct the client to empty the ostomy appliance once a day. B. Tell the client to notify the healthcare provider if the stoma becomes purple. C. Explain that a high-fiber diet should be followed for the first 6 to 8 weeks after ileostomy. D. Demonstrate and provide written instructions on how to irrigate the ostomy. 129. The community health nurse 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 effectiveness 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 program participants. D. Post announcements at the community center about upcoming topics. 130. A family member contacts the nurse at the community mental health center and wishes to share concerns and ask 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 this information. 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 helpful. 131. A family member brings a basket of fresh fruit to a client who has a decreased neutrophil count as a result of chemotherapy. What action should the nurse take regarding this gift? A. Encourage the client to eat the fruit as a small, healthy snack. B. Remove any of the fruit that provides high fiber. C. Encourage the client to eat the fruits that are high in vitamin C. D. Remove all of the fruit from the client’s room. 132. A male client who has a serum potassium level of 5.9 mEq tells the nurse that he has decided to leave the hospital, even though his healthcare provider has not discharged him. He also states that he does not care if he is discharged, he is refusing all treatments. It is most important for the nurse to ensure that the client understands which fact prior to leaving the facility? A. He must be informed that insurance will not pay for this hospital stay if he leaves against medical advice. B. He must sign the hospital’s Against Medical Advice (AMA) form, which will make him responsible for any consequences of not receiving medical care. C. He should know that he can return to the hospital at any time for treatment if he changes his mind. D. He must understand that his condition is extremely serious and that he could die as a result of his decision. 133. A 6-year-old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye. Which action should the school nurse take? A. Rinse the eye and gently remove the object. B. Remove the object and patch the eye. C. Call the parent and send the child home. D. Have the parent take the child for emergency help. 134. What is the rationale for the nurse to teach a client to compress the lacrimal duct after eye drop instillation? A. To prevent systemic absorption of the medication. B. To reduce pain and discomfort. C. To prevent irritation of the lacrimal gland. D. To reduce eye “tearing”. 135. Three days after surgery, a male client who had a laryngectomy has an elevated pulse and respiratory rates. His skin is dry to touch and he is beginning to thrash about in the bed. What intervention should the nurse implement first? A. Apply restraints to the client’s hands to prevent injury. B. Suction the client’s tracheostomy. C. Administer a sedative prescribed PRN for restlessness. D. Call the healthcare provider. 136. A client with chronic kidney disease (CKD) is scheduled for hemodialysis Monday and Wednesday mornings. Based on findings reported in the client’s medical record, which action should the nurse implement on Wednesday morning? A. Withhold the morning dose of lisinopril (Zestril). B. Keep the client NPO for hemodialysis. C. Notify the healthcare provider of the laboratory results. D. Give a PRN dose of aspart (Novolog) insulin. 137. A client just returned to the nursing unit after surgery, and initial assessment findings include a pulse rate of 120 beats/minute, restlessness, cyanosis, and gurgling sounds on inspiration and expiration. What action should the nurse take first? A. Perform oropharyngeal suctioning. B. Report the findings to the healthcare provider. C. Administer oxygen via a rebreathing mask. D. Bring intubation supplies to the room. 138. In shift report the charge nurse is told of several problems. Which problem should the nurse address first? A. A bucket of water was spilled in the hallway. B. A client’s wife has asked to speak with the charge nurse. C. The census report has not been completed. D. One staff member has not reported to work. 139. The nurse plans to administer an IV heparin bolus of 80 units/kg to a client who weighs 210 pounds. How many units should the nurse administer? 7636 140. The nurse administers NPH insulin to a child at 7:30 am. When should the insulin be most effective in lowering the blood sugar? A. Late evening to bedtime. B. Before lunchtime. C. During the night. 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 the site. B. Remove the original dressing. C. Secure the transparent dressing. D. Apply a facemask. 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. 143. A middle-aged female client is admitted to the hospital with a medical diagnosis of acute renal failure (ARF). The healthcare provider informs her that her treatment program 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.” 144. The nurse is assigning rooms for four clients, each newly diagnosed and being admitted to the acute neuro unit for treatment. The client with which diagnosis should be assigned the only private room available? A. Viral encephalitis. B. Septic shock. C. Brain abscess. D. Bacterial meningitis. 145. While assessing a client with wrist restraints, the nurse first slides two fingers under the restraint, and then notes that the ties are secured to the side rails using a quick-release tie. What action should the nurse implement? A. Reposition the restraint ties, securing them to the bed frame. B. Reapply the restraint, allowing less room under the restraint. C. Tie the restraints to the side rail using a more secure knot. D. Document that the client’s restraints are currently secured. 146. Which symptom in a client with fractured ribs indicates the presence of an abnormality warranting immediate intervention by the nurse? A. Asymmetrical chest wall excursion. B. Shallow respirations and refusing to take deep breaths. C. Complaints of chest pain with movement. D. Ecchymosis around fracture site. 147. A female client presents to the emergency department in the early evening complaining of abdominal cramping, watery diarrhea, and vomiting. She tells the nurse that she was at a picnic and ate barbeque that afternoon. What question is most important for the triage nurse to ask this client? A. “Have you taken any medication to treat this problem?” B. “Have you recently traveled outside the United States?” C. “Is anyone else sick who was also at the picnic?” D. “How high was your temperature when you returned home?” 148. While drawing a blood sample from a 2-month-old diagnosed with Tetrology of Fallot (TOF), the nurse recognizes the onset of a hypercyanotic spell or “tet spell”. After positioning the infant in a knee-chest position, what should the nurse administer? A. A systemic vasoconstrictor. B. Oxygen. C. Nothing until the episode is resolved. D. Morphine. 149. A male client diagnosed with gastroesophageal reflux (GERD) often wakes up at night experiencing heartburn. He tells the nurse that he sleeps with the head of the bed on blocks, and always drinks a glass of milk at bedtime to help him fall asleep. How should the nurse respond? A. “Drinking milk before bedtime can increase your symptoms