HESI RN EXIT EXAM 150 Questions and answers (Graded A+)

HESI RN EXIT EXAM 150 Questions and answers (Graded A+) 1. In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? - Correct answer C) Security" "2. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? - Correct answer B) "Would you please clarify what you have written so I am sure I am reading it correctly?"" "3. What is the most important consideration when teaching parents how to reduce risks in the home? - Correct answer D) Age of children in the home" "4. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should - Correct answer C) Administer the prescribed analgesia" "5. While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention? - Correct answer A) Respiratory rate of 42" "6. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings? - Correct answer A) Lethargy" "7. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? - Correct answer B) "The seizure may or may not mean your child has epilepsy."" "8. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies? - Correct answer A) Risk for injury" "9. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? - Correct answer B) Pale mucosa of the eyelids and lips" "10. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is - Correct answer D) Pupil responses" "11. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? - Correct answer D) A preschooler with intermittent episodes of alertness" "12. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be - Correct answer D) Pale, thin arms and legs, uninterested in surroundings" "13. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? - Correct answer D) Hair loss" "14. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to - Correct answer B) Administer acetaminophen as ordered as this is normal at this time" "15. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be - Correct answer B) Assess for dyspnea or stridor" "16. Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? - Correct answer D) I went to the bathroom and my urine looked very red and it didn't hurt when I went." "17. Which of these parents' comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? - Correct answer C) Mild vomiting that progressed to vomiting shooting across the room." "18. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings? - Correct answer B) Tissue hypoxia" "19. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet - Correct answer A) High in carbohydrates and proteins" "20. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant? - Correct answer C) Tripled the birth weight" "21. A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to - Correct answer B) Ask the client what foods are acceptable or bad" "22. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age? - Correct answer B) Imitation of sounds" "23. The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended? - Correct answer B) Withdrawal" "24. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner's injuries by - Correct answer B) Minimizing the episode and underestimating the victim's injuries" 25. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? - Correct answer B) "I have been coughing up foul-tasting, brown, thick sputum."" "26. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal - Correct answer A) S3 ventricular gallop" "27. Which of these observations made by the nurse during an excretory urogram indicate a complicaton? - Correct answer B) The client's entire body turns a bright red color" "28. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? - Correct answer B) "The tube will remove excess air from your chest."" "29. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? - Correct answer D) Serum potassium 6 mEq/L" "30. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? - Correct answer C) Dyspnea" "31. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? - Correct answer C) Pulse oximetry of 88" "32. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? - Correct answer D) Restlessness" "33. During the evaluation phase for a client, the nurse should focus on - Correct answer B) The client's status, progress toward goal achievement, and ongoing re-evaluation" "34. The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should - Correct answer C) Compile a history of behavior patterns and developmental accomplishments" "35. Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care? - Correct answer A) Measure head circumference" "36. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values? - Correct answer C) Bilirubin" "37. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct? - Correct answer D) Should be limited to 3-4 cups of milk daily" "38. The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client's behavior most likely indicates - Correct answer C) Flight of ideas" "39. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age? - Correct answer C) Riding a tricycle" "40. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is - Correct answer D) Moist saline dressing" "41. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!" What would be the most appropriate next action? - Correct answer A) Leave the room and return five minutes later and give the medicine" "42. A nurse is doing pre conceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome? - Correct answer C) "If I drink, my baby may be harmed before I know I am pregnant."" "43. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? - Correct answer C) Loss of pulse in the extremity" "44. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? - Correct answer C) Assist him to stand by the side of the bed to void" "45. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? - Correct answer B) Perform a quick assessment of the client's condition" "46. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? - Correct answer B) "I am allergic to shrimp."" "47. The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? - Correct answer A) Hold the tube feeding and notify the provider" "48. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must - Correct answer A) Apply suction for no more than 10 seconds" "49. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to - Correct answer A) Administer the medication in 2 separate injections B) Give the medication in the dorsal gluteal site C) Call to get a smaller volume ordered D) Check with pharmacy for a liquid form of the medication skip" "50. The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to - Correct answer A) Enhance absorption of the medication B) Ensure that the entire dose of medication is given C) Provide more even distribution of the drug D) Prevent the drug from tissue irritation Skip" "51. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? - Correct answer A) Diaphoresis with decreased urinary output B) Increased heart rate with increase respirations C) Improved respiratory status and increased urinary output D) Decreased chest pain and decreased blood pressure" "52. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? - Correct answer A) "As you urinate more, you will need less medication to control fluid." B) "You will have to take this medication for about a year." C) "The medication must be continued so the fluid problem is controlled." D) "Please talk to your health care provider about medications and treatments."" "53. A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? - Correct answer A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dsypnea, nasal congestion" "54. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? - Correct answer A. Cleanse the foot with soap and water and apply an antibiotic ointment B. Provide teaching about the need for a tetanus booster within the next 72 hours. C. have the mother check the child's temperature q4h for the next 24 hours D. transfer the child to the emergency department to receive a gamma globulin injection" "55. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences - Correct answer A. Bradycardia and constipation B. Lethargy and lack of appetite C. Muscle cramping and dry, flushed skin D. Palpitations and shortness of breath" "56. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? - Correct answer " "Obtain a list of medications taken for cardiac history 57. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) - Correct answer " "A. Fluid shifts from intravascular to interstitial area due to decreased serum protein B. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen C. Increased circulating aldosterone levels that increase sodium and water retention 58. The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) - Correct answer " "Murmur 59. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound? - Correct answer A) Transparent dressing B) Dry sterile dressing with antibiotic ointment C) Wet to dry dressing D) Occlusive moist dressing" "60. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? - Correct answer A) Cartoon stickers B) Large wooden puzzle C) Blunt scissors and paper D) Beach ball" "61. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the - Correct answer A) Yang, the positive force that represents light, warmth, and fullness B) Yin, the negative force that represents darkness, cold, and emptiness C) Use of improper hot foods, herbs and plants D) A failure to keep life in balance with nature and others" "62. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response? - Correct answer A) "There is a probability of life-long complications." B) "Cystic fibrosis results in nutritional concerns that can be dealt with." C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." D) "You will work with a team of experts and also have access to a support group that the family can attend."" "63. Which type of accidental poisoning would the nurse expect to occur in children under age 6? - Correct answer A) Oral ingestion B) Topical contact C) Inhalation D) Eye splashes" "64. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client? - Correct answer A) Reading B) Checkers C) Cards D) Ping-pong" "65. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? - Correct answer A) Widening pulse pressure B) Pleural friction rub C) Distended neck veins D) Bradycardia" "66. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? - Correct answer A) Assess for generalized edema B) Monitor for increased urinary output C) Encourage rest during hyperactive periods D) Note patterns of increased blood pressure" "67. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? - Correct answer A) Schedule the therapy thirty minutes after meals B) Teach the child not to cough during the treatment C) Confine the percussion to the rib cage area D) Place the child in a prone position for the therapy" "68. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? - Correct answer A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs" "69. 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? - Correct answer A) Three apricots B) Medium banana C) Naval orange D) Baked potato" "70. 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? - Correct answer A) Add a thickening agent to the fluids B) Check the client's gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids" "71. 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? - Correct answer A) Place client in the wheelchair for four hours each day B) Pad the bony prominence C) Reposition every two hours D) Massage reddened bony prominence" "72. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? - Correct answer A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic client" "73. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? - Correct answer A) Obtain a complete blood count B) Obtain a health and dietary history C) Refer to a provider for a physical examination D) Measure height and weight" "74. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is - Correct answer A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents" "75. 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? - Correct answer A) Allow the client to melt ice chips in the mouth B) Provide mints to freshen the breath C) Perform frequent oral care with a tooth sponge D) Swab the mouth with glycerin swabs" "76. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to - Correct answer A) Exercise doing weight bearing activities B) Exercise to reduce weight C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones" "77. 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? - Correct answer A) Cheese sandwich with a glass of 2% milk B) Sliced turkey sandwich and canned pineapple C) Cheeseburger and baked potato D) Mushroom pizza and ice cream" "78. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? - Correct answer A) All 4 side rails up, wheels locked, bed closest to door B) Lower side rails up, bed facing doorway C) Knees bent, head slightly elevated, bed in lowest position D) Bed in lowest position, wheels locked, place bed against wall" "79. 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? - Correct answer A) Bulimia B) Anorexia C) Obesity D) Malnutrition" "80. 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 - Correct answer A) Invite the client to join the exercise group B) Tell the client you will call someone to come for her C) Give the client simple information about what she will be doing D) Firmly direct the client to her assigned group activity" "81. 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? - Correct answer A) "The violence is temporarily caused by unusual circumstances, don't stop hoping for a change." B) "Perhaps, if you understood the need to abuse, you could stop the violence." C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?" D) "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do."" "82. A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation? - Correct answer A) Degeneration of the alveoli B) Chronic broncho constriction of the large airways C) Lung remodeling and permanent changes in lung function D) Frequent pneumonia" "83. A mother wants to switch her 9 month-old infant from an iron fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse? - Correct answer A) Change the baby to whole milk B) Add chocolate syrup to the bottle C) Continue with the present formula D) Offer fruit juice frequently" "84. Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice? - Correct answer A) When a family member offers information about their loved one B) When the client threatens self-harm and harm to others C) When the health care provider decides the family has a right to know the client's diagnosis D) When a visitor insists that the visitor has been given permission by the client" "85. The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care? - Correct answer A) Monitor for hyperkalemia B) Place in protective isolation C) Precautions with position changes D) Administer diuretics as ordered" "86. The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment? - Correct answer A) Activity intolerance caused by fatigue related to chronic tissue hypoxia B) Impaired mobility related to chronic obstructive pulmonary disease C) Self-care deficit caused by fatigue related to dyspnea D) Ineffective airway clearance related to increased bronchial secretions" "87. The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure? - Correct answer A) Standing and sitting B) In both arms C) After exercising D) Supine position" "88. The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group? - Correct answer A) Aerobic exercise classes B) Transportation for shopping trips C) Reminiscence groups D) Regularly scheduled social activities" "89. Post-procedure nursing interventions for electroconvulsive therapy include - Correct answer A) Applying hard restraints if seizure occurs B) Expecting client to sleep for 4 to 6 hours C) Remaining with client until oriented D) Expecting long-term memory loss" "90. The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding? - Correct answer A) Stand on 1 foot B) Catch a ball C) Skip on alternate feet D) Ride a bicycle" ". 91. The mother of a 15 month-old child asks the nurse to explain her child's lab results and how they show her child has iron deficiency anemia. The nurse's best response is - Correct answer A) "Although the results are here, your doctor will explain them later." B) "Your child has less red blood cells that carry oxygen." C) "The blood cells that carry nutrients to the cells are too large." D) "There are not enough blood cells in your child's circulation."" "92. In a child with suspected coarctation of the aorta, the nurse would expect to find - Correct answer A) Strong pedal pulses B) Diminishing carotid pulses C) Normal femoral pulses D) Bounding pulses in the arms" "93. At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates - Correct answer A) Feelings of increasing anxiety related to paranoia B) Social isolation related to altered thought processes C) Sensory perceptual alteration related to withdrawal from environment D) Impaired verbal communication related to impaired judgment" "94. A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0- to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to - Correct answer A) Ask the client about the refusal of certain pain medications B) Talk with the client's family about the situation C) Report the situation to the health care provider D) Document the situation in the notes" "95. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? - Correct answer A) Presence of blood in stools B) Oozing liquid stool C) Continuous rumbling flatulence D) Absence of bowel movements" "96. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to - Correct answer A) Have the client identify coping methods B) Get the description of the location and intensity of the pain C) Accept the client's report of pain D) Determine the client's status of pain" "97. An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be - Correct answer A) Assess the severity and location of the pain B) Obtain an order for an analgesic C) Reassure him that this is not unusual for his age D) Encourage him to increase his activity" "98. A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: - Correct answer A) Visitors must wear a mask and a gown B) There are no special requirements for visitors of clients on contact precautions C) Visitors should wash their hands before and after touching the client D) Visitors" "99. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? - Correct answer A) Institute seizure precautions B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h" "100. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? - Correct answer A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia" "100. A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? - Correct answer A) An infant who has been identified to have botulism B) A toddler who ate a number of ibuprofen tablets C) A preschooler who swallowed powdered plant food D) A school aged child who took a handful of vitamins" "101. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? - Correct answer A) Apply appropriate signs outside and inside the room B) Apply a mask with a shield if there is a risk of fluid splash C) Wear a gown to change soiled linens from incontinence D) Have gloves on while handling bedpans with feces" "102. Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? - Correct answer A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin" "103. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? - Correct answer A) Reverse B) Airborne C) Standard precautions D) Contact" "104. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? - Correct answer A) "The treatment requires reapplication in 8 to 10 days." B) "Bedding and clothing can be boiled or steamed." C) Children are not to share hats, scarves and combs. D) Nit combs are necessary to comb out nits." "105. During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? - Correct answer A) Wash hands thoroughly before and after client contact B) Wear gloves when in contact with body secretions C) Double glove when in contact with feces or vomitus D) Wear gloves when disposing of contaminated linens" "106. A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes? - Correct answer A) Grilled chicken sandwich and skim milk B) Roast beef, mashed potatoes, and green beans C) Peanut butter sandwich, banana, and iced tea D) Barbecue beef, baked beans, and cole slaw" "107. After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, "My husband told me to get treatment or he would divorce me. I don't believe I really need treatment but I don't want my husband to leave me." Which response by the nurse would assist the client? - Correct answer A) "In early recovery, it's quite common to have mixed feelings, but unmotivated people can't get well." B) "In early recovery, it's quite common to have mixed feelings, but I didn't know you had been pressured to come." C) "In early recovery it's quite common to have mixed feelings, perhaps it would be best to seek treatment on an out client bases." D) "In early recovery, it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you."" "108. A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passes loose, watery stool. Which of these is a nursing priority? - Correct answer A) Hold the infant at frequent intervals. B) Assess for neonatal withdrawal syndrome C) Offer fluids to prevent dehydration D) Administer paregoric to stop diarrhea" "109. The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to - Correct answer A) Dehydration B) Diminished blood volume C) Decreased cardiac output D) Renal failure" "110. The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is - Correct answer A) Pain B) Impaired gas exchange C) Cardiac output altered: decreased D) Fluid volume excess" "111. The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the health care provider? - Correct answer A) Lifts head from the prone position B) Rolls from abdomen to back C) Responds to parents' voices D) Falls forward when sitting" "112. A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other measure should the nurse implement? - Correct answer A) Have respiratory support equipment available B) Immediately place her in the seclusion room C) Assess the client for anxiety and agitation D) Administer PRN dose of IM antipsychotic medication" "113. The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first - Correct answer A) Assess the client's airway B) Call for help C) Establish that the client is unresponsive D) See if anyone saw the client fall" "114. The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to - Correct answer A) Check for subcutaneous emphysema in the upper torso B) Reposition the client to a position of comfort C) Call the health care provider as soon as possible D) Check for any increase in the amount of thoracic drainage" "115. The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these demonstrates the normal pathway? - Correct answer A) AV node, SA node, Bundle of His, Purkinje fibers B) Purkinje fibers, SA node, AV node, Bundle of His C) Bundle of His, Purkinje fibers, SA node , AV node D) SA node, AV node, Bundle of His, Purkinje fibers" "116. When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first? - Correct answer A) Try to vigorously stimulate normal breathing B) Ask the RN to assess the vital signs C) Measure the pulse oximetry D) Continue to monitor respirations" "117. When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because - Correct answer A) Normal patterns of behavior may be labeled as deviant, immoral, or insane B) The meaning of the client's behavior can be derived from conventional wisdom C) Personal values will guide the interaction between persons from 2 cultures D) The nurse should rely on her knowledge of different developmental mental stages" "118. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client? - Correct answer A) Assign an RN to provide total care of the client B) Assign a nursing assistant to help the client with self-care activities C) Delegate complete care to an unlicensed assistive personnel D) Supervise a nursing assistant for skin care" "119. The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process? - Correct answer A) Assist a client post cerebral vascular accident to ambulate B) Feed a 2 year-old in balanced skeletal traction C) Care for a client with discharge orders D) Collect a sputum specimen for acid fast bacillus" "120. After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond by saying - Correct answer A) "He has a lot of problems. You need to have patience with him." B) "I will talk with him and try to figure out what to do." C) "He is scared and taking it out on you. Let's talk to figure out what to do." D) "Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day."" "121. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements? - Correct answer A) I am sorry. Referral information can only be provided by the client's health care providers. B) "I can never give any information out by telephone. How do I know who you are?" C) Since this is a referral, I can give you this information. D) I need to get the client's written consent before I release any information to you." "122. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that - Correct answer A) A referral is needed to the psychiatrist who is to provide the client with answers B) The client has a right to know about the prescribed medications C) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications D) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects" "123. Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time? - Correct answer A) "Have the client sit on the side of the bed for at least 2 minutes before helping him stand." B) "If the client is dizzy on standing, ask him to take some deep breaths." C) "Assist the client to the bathroom at least twice on this shift." D) "After you assist him to the chair, let me know how he feels."" "124. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client - Correct answer A) Has had a change in respiratory rate by an increase of 2 breaths B) Has had a change in heart rate by an increase of 10 beats C) Was minimally responsive to voice and touch D) Has had a blood pressure change by a drop in 8 mmHg systolic" "125. A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is - Correct answer A) "I must document and report any information." B) "I can't make such a promise." C) "That depends on what you tell me." D) "I must report everything to the treatment team."" "126. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? - Correct answer A) Be with a client who self-administers insulin B) Cleanse and dress a small decubitus ulcer C) Monitor a client's response to passive range of motion exercises D) Apply and care for a client's rectal pouch" "127. A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first - Correct answer A) Focus on reality orientation to place and person B) Assist with the report of the client's complaint to the police C) Obtain more details of the client's claim of abuse D) Document the statement on the client's chart with a report to the manager" "128. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with - Correct answer A) A Dopamine drip IV with vital signs monitored every 5 minutes B) A myocardial infarction that is free from pain and dysrhythmias C) A tracheotomy of 24 hours in some respiratory distress D) A pacemaker inserted this morning with intermittent capture" "129. An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions? - Correct answer A) "How long have you been a UAP and what units you have worked on?" B) "What type of care do you give on the surgical unit and what ages of clients?" C) "What is your comfort level in caring for children and at what ages?" D) "Have you reviewed the list of expected skills you might need on this unit?"" "130. A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse's response should be to - Correct answer A) Ask to not be assigned to this client or to work on another unit B) Tell the client that such behavior is inappropriate C) Inform the client that hospital policy prohibits staff to date clients D) Discuss the boundaries of the therapeutic relationship with the client" "131. In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize - Correct answer A) Learning relaxation techniques B) Limiting alcohol use C) Eating smaller meals D) Avoiding passive smoke" "132. The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance? - Correct answer A) Arterial septal defect B) Patent ductus arteriosus C) Aortic stenosis D) Ventricular septal defect" "133. Clients with mitral stenosis would likely manifest findings associated with congestion in the - Correct answer A) Pulmonary circulation B) Descending aorta C) Superior vena cava D) Bundle of His" "134. The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women? - Correct answer A) Low tar cigarettes are less harmful during pregnancy B) There is a relationship between smoking and low birth weight C) The placenta serves as a barrier to nicotine D) Moderate smoking is effective in weight control" "135. What is the best way for the nurse to accomplish a health history on a 14 year-old client? - Correct answer A) Have the mother present to verify information B) Allow an opportunity for the teen to express feelings C) Use the same type of language as the adolescent D) Focus the discussion of risk factors in the peer group" "136. What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero? - Correct answer A) The disease will incubate longer and progress more slowly in this infant B) The infant is very susceptible to infections C) Growth and development patterns will proceed at a normal rate D) Careful monitoring of renal function is indicated" "137. While planning care for a preschool aged child, the nurse understands developmental needs. Which of the following would be of the most concern to the nurse? - Correct answer A) Playing imaginatively B) Expressing shame C) Identifying with family D) Exploring the playroom" "138. A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important to emphasize to the client? - Correct answer A) Maintain a low sodium diet B) Take a diuretic with lithium C) Come in for evaluation of serum lithium levels every 1-3 months D) Have blood lithium levels drawn during the summer months" "139. While teaching a client about their medications, the client asks how long it will take before the effects of lithium take place. What is the best response of the nurse? - Correct answer A) Immediately B) Several days C) 2 weeks D) 1 month" "140. The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include - Correct answer A) Pointing out inconsistencies in speech patterns to correct thought disorders B) Accepting client and the client's behavior unconditionally C) Encouraging dependency in order to develop ego controls D) Consistent limit-setting enforced 24 hours per day" "141. Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called - Correct answer A) Craving B) Crashing C) Outward bound D) Nodding out" "142. The nurse asks a client with a history of alcoholism about the client's drinking behavior. The client states "I didn't hurt anyone. I just like to have a good time, and drinking helps me to relax." The client is using which defense mechanism? - Correct answer A) Denial B) Projection C) Intellectualization D) Rationalization" "143. One reason that domestic violence remains extensively undetected is - Correct answer A) Few battered victims seek medical care B) There is typically a series of minor, vague complaints C) Expenses due to police and court costs are prohibitive D) Very little knowledge is currently known about batterers and battering relationships" "144. A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find? - Correct answer A) S3 heart sound B) Thready pulse C) Flattened neck veins D) Hypoventilation" "145. An explosion has occurred at a high school for children with special needs and severe developmental delays. One of the students accompanied with a parent is seen at a community health center a day later. After the initial assessment the nurse concludes that the student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next? - Correct answer A) Help the student to identify a specific problem B) Ask the parent to identify the major problem C) Ask the student to think of different alternatives D) Examine with the parent a variety of options" "146. Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode? - Correct answer A) "I think all children should have their heads shaved." B) "I have been restricted in thought and harmed." C) "I have powers to get you whatever you wish, no matter the cost." D) "I think all of my contacts last week have attempted to poison me."" "147. A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." The nurse would document this behavior as - Correct answer A) Perseveration B) Circumstantiality C) Neologisms D) Flight of ideas" "148. During the change-of-shift report the assigned nurse notes a Catholic client is scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of prejudice? - Correct answer A) "I wonder who is paying for this trip to the hospital?" B) "I think she needs to go to the city hospital." C) "All those people indulge in large families!" D) "Doesn't she know there's such a thing as birth control?"" "149. Which of these statements by the nurse reflects the best use of therapeutic interaction techniques? - Correct answer A) "You look upset. Would you like to talk about it?" B) "I'd like to know more about your family. Tell me about them." C) "I understand that you lost your partner. I don't think I could go on if that happened to me." D) "You look very sad. How long have you been this way?"" "150. A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first? - Correct answer A) Ask client if there are any old injuries also present B) Interview the client without the persons who came with the client C) Gain client's trust by not being hurried during the intake process D) Photograph the specific injuries in question"