HESI RN EXIT Exam Questions & Answers Latest Update 2023 Graded A

1. A female client at 10 weeks' gestation complains to her physician of slight vaginal bleeding and mild cramps. On examination, her physician determines that A threatened abortion An incomplete abortion 2. The nurse is assigned to a client with Parkinson's disease. Which findings would the nurse anticipate? Echolalia and a shuffling gait 3. A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to: Promote fetal lung maturation 4. A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should: Notify the physician immediately 5. A client is to have a coronary artery bypass graft performed in the morning using a saphenous vein. He wants to know why the physician does not use the internal mammary artery for his bypass graft because his friend's physician uses this artery. The nurse tells the client that the internal mammary artery: Takes more time to remove 6. A client returns to the cardiovascular intensive care unit following his coronary artery bypass graft. In planning his care, the most important electrolyte the nurse needs to monitor will be: Potassium 7. A client is being discharged from the hospital today. The discharge teaching for care of her colostomy included which of the following basic principles for protecting the skin around her stoma: Using a skin sealant under pouch adhesives 8. 9. A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should: Give the client his order of Demerol 50 mg IM prn 10. A client has returned to the unit from the recovery room after having a thyroidectomy. The nurse knows that a major complication after a thyroidectomy is: Respiratory obstruction 11. A client had a transurethral resection of the prostate yesterday. He is concerned about the small amount of blood that is still in his urine. The nurse explains that the blood in his urine: Is normal and he need not be concerned about it 12. A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that: This is usually temporary 13. A 48-year-old female client is going to have a cholecystectomy in the morning. In planning for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for: Ineffective breathing pattern 14. A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include: Monitoring the right lung for an increase in rales 15. A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first: Notify the physician. 16. A client had a renal transplant 3 months ago. He has suddenly developed graft tenderness, an increased white blood cell count, and malaise. The client is experiencing which type of rejection? Acute 17. A client hasreceived preoperative teaching for the vertical partial laryngectomy that he is scheduled to have in the morning. The nurse determines that the teaching has been effective when the client states: "I will have very little difficulty swallowing aftersurgery." 18. A client being discharged from the hospital is beginning medication therapy with bumetanide (Bumex). The nurse instructs the client to contact the prescriber if which of the following contraindications for use develops while using this medication? Absence of urine output 19. The nurse should review the results of which of the following to evaluate a client's response to a lipid‐ lowering agent Liver function tests 20. An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply. . Skin tenting . Flat neck veins . Weak peripheral pulses 22 Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client? . Drowsiness 23 A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client? . Epistaxis 24 A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk? . Count wet diapers to be sure that the infant is having at least six to 10 each day 25 A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information? . "Wearing the brace is really important in curing the scoliosis." 26 Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with: . Tomato juice 27 A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally: . Decrease 28 A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that: . Pitting edema is present 29 A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would: . Document the findings Correct 30 After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client? . Replacement of the uterus through the vagina into a normal position 31 A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would: . Recheck the temperature in 4 hours 32 -A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse’s initial action should be: . Helping the woman empty her bladder 33-A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time? . Anxiety 34. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? Note patterns of increased blood pressure 35. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? Confine the percussion to the rib cage area 36. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? A) Orthostatic hypotension is a common side effect 37. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? D) Baked potato 38. An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? Check the client's gag reflex 39. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? C) Reposition every two hours 40. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? C) A client who had 3 incontinent diarrhea stools 41. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? A) Obtain a complete blood count 42. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is B) Auscultation 43. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client? A) Allow the client to melt ice chips in the mouth 44. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to C) Avoid exercise activities that increase the risk of fracture 45. The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? A) Cheese sandwich with a glass of 2% milk 46. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? B) Lower side rails up, bed facing doorway 47.The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group? D) Malnutrition 48. At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should Give the client simple information about what she will be doing 49. A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse? "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?" 50. A nurse observes a family member administer a rectalsuppository by having The client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? B) That was done correctly. Did you have any problems with the insertion? 51. A client with a diagnosis of Methicillin resistant Staphylococcus aureus(MRSA) Has died. Which type of precautions is the appropriate type to use when performing postmortem care? C) contact precautions 52. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? B) clean the meatus, begin voiding, then catch urine stream 53. The provider orders Lanoxin (digoxin) 0.125 mg POand furosomide 40mg Every day. Which of these foods would the nurse reinforce for the client to eat atleast daily? B) watermelon 54. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? C) Immediately wash the hands with vigor 55. As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.” The 56. A client with Guillain Barre is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? B) Glascow Coma Scale 8, respirations regular 57. A client enters the emergency department unconscious via ambulance from the client’s work place. What document should be given priority to guide the direction of care for this client? C) A notarized original of advance directives brought in by the partner 58. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? A) An admission at the change of shifts with atrial fibrillation and heart failure - PN 59. A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? B) Restlessness and increased mucus production 60. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? C) "Clothes are becoming tighter across her abdomen." 61. A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? D) Proceed with the triage process in the same manner as any adult client 62. A newly admitted elderly client is severely dehydrated. When planning care for This client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? B) Report hourly outputs of less than 30 ml/hr 63. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with thisdisease? B) Strep throat went through all the children at the day care last month. 64. A nurse assigned to a manipulative client for 5 days becomes awareof feelings for a reluctance to interact with the client. The next action by the nurse shouldbe to A) Discuss the feeling of reluctance with an objective peer or supervisor 65. A client is being treated for paranoid schizophrenia. When the clientbecame loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action A) May result in charges of unlawful seclusion and restraint 66. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? A) Pain related to ischemia 67. The provisions of the law for the Americans with Disabilities Act require Nurse managers to B) Provide reasonable accommodations for disabled individuals 68. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance? C) "I have diminished sexual function." 69. A school-aged child has had a long leg (hip to ankle)synthetic castapplied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate? D) ”I think I remember that standing cannot be done until after 72 hours." The 70. Which statement best describes time management strategies appliedto the role of a nurse manager? C) Set daily goals with a prioritization of the work 71. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated withthis problem include which of these? D) Abdominal mass and weakness 72. A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? A) "I will only have to wear this for 6 months." 73. 5.Padding on a restraint helps: A. with pressure distribution so that bony prominences do not receive pressure when a client pulls against the restraints. 74. Paula is a 32-year-old woman seeking evaluation and treatment of major depressive symptoms. A major nursing priority during the assessment process includes which of the following? B. possibility of self-harm 75.A client is assessed by the nurse as experiencing a crisis. The nurse plans to: C. focus on immediate stress reduction. 76. A client is having psychological counseling for problems communicating with his mother. Which model of stress is the most useful in reference to this stressor? C. Transaction-Based Model 77.A female having her first child is experiencing which type of crisis event? B. maturational 78.Nursing care for a client undergoing chemotherapy includes assessment for signs of bone marrow depression. Which finding accounts for some of the symptoms related to bone marrow depression? D. thrombocytopenia 79. A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is under way and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate? D. No action is necessary. 80.A serious complication of a total hip replacement is displacement of the prosthesis. What is the primary sign of displacement? A. pain on movement and weight bearing 81. Which of the following instructions should a nurse give a client who is about to undergo pelvic ultrasonography? D. "Drink plenty of water." 82.Which of the following is not a reason for pelvic ultrasonography? C. to measure renal size 83. Which physiologic mechanism best describes the function of the sodium-potassium pump? A. active transport 84. Laboratory tests reveal the following electrolyte values for Mr. Smith: Na 135 mEq/L, Ca 8.5 mg/dL, Cl 102 mEq/L, and K 2.0 mEq/L. Which of the following values should the nurse report to the physician because of its potential risk to the client? B. K 85. A client receiving drug therapy with furosemide and digitalis requires careful observation and care. In planning care for this client, the nurse should recognize that which of the following electrolyte imbalances is most likely to occur? C. hypokalemia 86. A nurse is assessing the fetal heart rate for a client who is at 38 weeks of gestation. When using an ultrasound device, the nurse hears blood rushing through the umbilical vessels in synchronization with the fetal heartbeat. Which of the following terms should the nurse use to document this finding? a. Funic soufflé 87. A nurse manager in a newborn nursery is reviewing infection control procedures with a group of newly hired nurses. Which of the following instructions should the nurse manager include in the teaching? a. Allow parents to enter the nursery if they are wearing a mask 88. A nurse is caring for a client who is 8 hr postpartum following vaginal delivery and is unable to void. Which of the following interventions should the nurse use to promote voiding? b. Insert an indwelling urinary catheter 89. A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching? a. Transmission can occur via the saliva and urine of the newborn 90. A nurse in a prenatal clinic is caring for a client who has hyperemesis gravidarum. Which of the following is the initial laboratory test used to evaluate this condition? d. Urine ketones 91. A nurse in a prenatal clinic is reviewing the laboratory results for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take? (Click on the Exhibit button for additional information about the client. There are three tabs that contain separate categories of data.) Try your best guess and judgment! d. Obtain a maternal serum alpha-fetoprotein specimen – NO, test occurs between 15-22 wks 92. A nurse is teaching a client about the basal body temperature method of contraception. Which of the following statements should the nurse include in the teaching? b. You should take your temperature before getting up for the day 93. A nurse is providing education to a client who is to receive misoprostol for induction of labor. Which of the following instructions should the nurse include in the teaching? c. You will lie on your side for 40 minutes after I administer the medication 94. A nurse is planning care for a client in the postpartum unit. Which of the following goals should the nurse identify for the client to accomplish during the taking-in phase of postpartum adjustment? d. The client will have adequate nutritional intake 95. A nurse in the antepartum clinic is teaching a client who is at 28 weeks of gestation and has preeclampsia. Which of the following instructions should the nurse include in the teaching? c. Count your baby’s movements daily 96. A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B Streptococcus B-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse? d. We need to know if you are positive for GBS at the time of delivery 97. A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider? d. Transient circumoral cyanosis – decreased oxygenation 98. A nurse is caring for a client who is postpartum and experiencing hypovolemic shock. Which of the following findings should the nurse expect? d. Cool, clammy skin 99. A nurse is teaching a client who is at 8 weeks of gestation about self-care during pregnancy. Which of the following statements should the nurse make? d. You should take 600 mcg of folic acid per day 100. A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan? c. Maintain the client in a supine position?? Best Answer? 101. A nurse is providing teaching about expected changes during pregnancy to a client who is at 24 weeks of gestation. Which of the following information should the nurse include? c. You should anticipate nasal stuffiness 102. A nurse is assisting the provider to administer a dinoprostone (Cervidil) insert to induce labor for a client. Which of the following actions should the nurse take? c. Verify that the informed consent is obtained prior to administration 103. After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client? D. Replacement of the uterus through the vagina into a normal position A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would: B. Recheck the temperature in 4 hours 105 -A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse’s initial action should be: C. Helping the woman empty her bladder 106-A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time? A. Anxiety 107 -A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client? C. Positive result on d-dimer study 108 -A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply. A. Tachycardia D. Diminished peripheral pulses 109- A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock? D. Placing the client in a lateral position with the bed flat 110 -A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician? D. Reddish lochia on postpartum day 8 111 A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to: A. Document the findings Correct 112- A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta? B. "The placenta maintains the body temperature of my baby." Correct 113 -A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele’s rule, the nurse determines that the estimated date of delivery (EDD) is: B. July 2, 2013 Correct 114 A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication? A. Steak Correct 115 -A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy? D. White blood cell count of 2500 cells/mm3 116 -Which finding in a client’s history indicates the greatest risk of cervical cancer to the nurse? C. Multiple sexual partners 117. When teaching new parents to prevent Sudden Infant Death Syndrome (SIDS) what is the most important practice the nurse should instruct them to do? A) Place the infant in a supine or side lying position for sleep 118. A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize the client knowing that gradual emptying is preferred over complete emptying because it B) Reduces the potential for shock 119. A client is admitted with a medical diagnosis of addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations? Hypotension, rapid weak pulse, and rapid respiratory rate 120. The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction? The nurse is caring for critically ill clients. Which should be monitored for the development of neutogenic shock? A client with? Spinal cord injury 121. Which statement by the community health nurse is most helpful to an adult who is in a crisis situation? You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it? 122. The nurse is teaching staff in a long term - facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension? Frequent blood pressure checks, including readings taken automated machines are recommended 123. A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission? Monitor for increased blood pressure and pulse 124. A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat diet, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. what intervention should the nurse implement? Confront the client about the consequences of the behavior. 125. A child with tetrology of ballot suffers a hyper cyanotic episode. Which immediate action by the nurse can lessen the symptoms of this " TET" spell? Place child in knee-chest positionThis pressure reduces the rush of blood flow through the septal hole and improves blood circulation. 126. A client with metastatic cancer is preparing to make a decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate? It will identify someone that can make the decisions for you health care if you are ever in a coma or vegetative state. 127.After eye drops are instilled, which instruction should the nurse provide to the client? Close your eyelids 128. The nurse is preparing to administer IV fluid to a client with strict fluid restriction. IV tubing with which feature is most important for the nurse to select? A Buretrol Attachment 129. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to A) go get a blood pressure check within the next 48 to 72 hours 130. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is C) Manage pain 131. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 132. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? C) "I understand the need to use those new skills." 133. A male client is admitted to the medical-surgical unit from the emergency room with a diagnosis of acute pancreatitis. The nurse performs the admission nursing assessment. He is NPO with IV fluids infusing at 100 mL/hour. He is experiencing excruciating abdominal pain. Based on an analysis of these data, which nursing diagnosis would receive the highest priority? A. Pain related to stimulation of nerve endings associated with obstruction of the pancreatic tract 134. A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client’s selfesteem by: D. Allowing him to plan, assist in, and perform his own care whenever possible 135. A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures? A. Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing. 136. A male client has experienced low back pain for several years. He is the primary support of his wife and six children. Although he would qualify for disability, he plans to continue his employment as long as possible. His back pain has increased recently, and he is unable to control it with nonsteroidal anti-inflammatory agents. He refuses surgery and cannot take narcotics and remain alert enough to concentrate at work. His physician has suggested application of a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following is an appropriate rationale for using a TENS unit for relief of pain? C. TENS units work on the gate-control theory of pain; biostimulation therapy of large fibers block painful stimuli. 137. A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed. Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management? B. The basis for phantom pain may occur because the nerves still carry pain sensation to the brain even though the limb has been amputated. The pain is real, intense, and should be treated. 138. A 28-year-old woman was admitted to the hospital for a thyroidectomy. Postoperatively she is taken to the postanesthesia care unit for several hours. In preparing for the client’s return to her room, which nursing measure best demonstrates the nurse’s thorough understanding of possible postthyroidectomy complications? C. A tracheostomy set, O2, and suction are available at the bedside. 139. A male client is diagnosed with hypoparathyroidism. He has been on dialysis for several years. He is experiencing symptoms such as numbness of the lips, muscle weakness, carpopedal spasms, and wheezing. Given the client’s symptoms, nursing assessment would focus on: A. Detection of tetany 140.A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of: B. Aspiration and weight loss 141. A 70-year-old female client is admitted to the medical intensive care unit with a diagnosis of cerebrovascular accident (CVA). She is semicomatose, responding to pain and change in position. She is unable to speak or cough. In planning her nursing care for the first 24 hours following a CVA, which nursing diagnosis should receive the highest priority? A. Ineffective airway clearance related to immobility, ineffective cough, and decreased level of consciousness 142. A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is: B. "No, but you will have to lie still and the gel that is used may be cool." 143. A 17-year-old client has a T-4 spinal cord injury. At present, he is learning to catheterize himself. When he says, "This is too much trouble. I would rather just have a Foley.” An appropriate response for the RN teaching him would be: A. "I know. It is a lot to learn. In the long run, though, you will be able to reduce infections if you do an intermittent catheterization program.” 144. A client’s physician has prescribed theophylline (Theo- Dur) to help control the bronchospasm associated with the client’s COPD. Instructions that should be given to the client include: A. "Call your physician if you develop palpitations, dizziness, or restlessness.” 145. A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to: C. Return to the hospital immediately if he develops confusion, nausea, or vomiting 146. A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his beclomethasone, the client should be instructed to: B. Drink a glass of water 147. A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side. The nurse identifies the most likely cause of this as: B. Left-sided pneumothorax C. Right mainstem bronchus intubation 148. A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to: A. Prevent air from entering the pleural space B. Prevent fluid from entering the pleural space 149.A client was admitted with rib fractures and a pneumothorax, which were sustained as a result of a motor vehicle accident. A chest tube was placed on the left side to reinflate his lung, and he was transferred to a client unit. Twenty-four hours after admission he continues to have bloody sputum, develops increasing hypoxemia, and his chest x-ray shows patchy infiltrates. The nurse analyzes these symptoms as being consistent with: B. Pulmonary contusions 150. A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg; PCO2 55 mm Hg; HCO3 32 mEq/L. These blood gases reflect: B. Compensated respiratory acidosis 151. A female client who has chronic obstructive pulmonary disease (COPD) has presented in the emergency department with cough productive of yellow sputum and increasing shortness of breath. On room air, her blood gases are as follows: pH 7.30 mm Hg, PCO2 60 mm Hg, PO2 55 mm Hg, HCO3 32 mEq/L. These arterial blood gases reflect: D. Uncompensated respiratory acidosis Answer: D 152. A 19-year-old client has sustained a C-7 fracture, which resulted in his spinal cord being partially transected. By 2 weeks’ postinjury, his neck has been surgically stabilized, and he has been transferred from the intensive care unit. A potential life-threatening complication the nurse monitors the client for is: A. Autonomic dysreflexia 153. A client had a vaginal delivery 3 days ago and is discharged from the hospital on the 2nd day postpartum. She told the RN, "I need to start exercising so that I can get back into shape. Could you suggest an exercise I could begin with?” The RN could suggest which one of the following? D. Kegel exercises 154. A nurse understands that a patient may experience pain during peritoneal dialysis because of which ofthe following? Select all that apply: Too rapid installation Accumulation of dialysate solution under the diaphragm 155. The nurse is evaluating a client’s response to hemodialysis. Which lab results will indicate the dialysiswas effective? Select all that apply: Serumpotassiumlevel decreasesfrom5.4 to 4.6mEq/L Cr decreases from 1.6 to 0.8 mg/dLBUN decreasesfrom 110 to 90 mg/dL The nurse understands that the following clinical findings are indications for dialysis. Select all thatapply: Volume overload K 5.2 mEq/L Metabolic acidosis Cr 5.0 mg/dL 157. The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding would cause the nurse concern regarding the development of compartment syndrome? Select all that apply: Paresthesia distal to area of injury. Toes on affected leg cool to touch and edematous. Complaints of leg pain unrelieved by analgesics or repositioning. 158. The nurse is preparing discharge for a patient with GERD. What would be important for the nurse to include in this teaching plan? Select all that apply: Elevate the HOB. Decrease intake of caffeine. Discuss strategies for weight loss if overweight. Take ranitidine (Zantac) at hs. 159. The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure. Select all that apply: Verify consent has been signed. Explain procedure to client. Obtain a 12 lead ECG Obtain history of shellfish allergy. 160. The nurse has been assigned a group of cardiac clients. What would be the most important information for the nurse to check on the initial evaluation of each client? Select all that apply: Presence of cardiac pain. Presence of jugular vein distention. Heart sounds and apical rate. Presence of diaphoresis.