NGN Exit hesi
2 days prior to discharge from the rehab facility, the nurse is teaching a pt who is recovering from Guillain-Barre
syndrome about home. Which actions should the nurse include when providing discharge teaching to the pt and
spouse? SATA - Correct Answer -review safe transfer strategies
-develop a nutritional plan
-help identify community support
A 12 week gestation is admitted to the antepartum unit with a dx of hyperemesis gravidarum. Which action is most
important for the nurse to implement? - Correct Answer initiate prescribed IV fluids
A client fell in the bathroom when left unattended by the UAP. Which information should the nurse include in the pt
health record? - Correct Answer The pt fell sustaining a fracture to the left hip
A client presents to the emergency dept with muscle aches, headache, fever, and describes a recent loss of taste
and smell. The nurse obtains a swab for COVID -19 testing. Which action is most important for the nurse to take? -
Correct Answer place the nasal swab specimen for COVID 19 directly in a biohazard bag.
A client with urge incontinence was treated with onabotulinumtoxinA injections and is now experiencing urinary
retention. Which action should the nurse include in the client's plan of care? - Correct Answer Remind the pt to
practice pelvic floor exercises regularly.
A male client approaches the nurse with an angry expression on his face and raises his voice, saying, "My roommate
is the most selfish, self-centered, angry person I have ever met If he loses his temper one more time with me, I am
going to punch him." The nurse recognizes that the pt is using which defense mechanism? - Correct Answer
Projection
A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at
night with no relief of his discomfort. Which action should the nurse take? - Correct Answer Encourage the pt to use
cooler water and apply calamine lotion after soaking.
A new nurse preparing to irrigate an IV catheter is attaching a 24 gauge needle. Which action should the charge
nurse implement? - Correct Answer Suggest the nurse use 20g needle
A nurse receives a report on a pt who is four hours post-total abdominal hysterectomy. The previous nurse reports
that it was necessary to change the client's perineal pad hourly and that it is again saturated. The previous nurse also
reports that the client's urinary output has decreased. Which action should the nurse implement first? - Correct
Answer Assess for weakness or dizziness
A nurse who is working in the emergency department triage area is presented with four clients at the same time. The
client presenting with which symptoms require the most immediate intervention by the nurse? - Correct Answer Chest
discomfort one hour after consuming a large spicy meal.
A nurse working on an Endocrine Unit should see which client first? - Correct Answer A pt taking corticosteroids who
has become disoriented in the last two hours.
A patient who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several
side effects since taking the med. Which side effect should the nurse report to the healthcare provider? - Correct
Answer Somnambulism
A pediatric client is taking the beta-adrenergic blocking agent propranolol. In developing a teaching plan, the nurse
should teach the parents to report which sign of overdose? - Correct Answer Bradycardia
A preschool aged boy is admitted to the pediatric unit following successful resuscitation from a near drowning
incident. While providing care to the child, the nurse begins with the brother who rescued the child from the swimming
pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what
happened. Which action should the nurse take? - Correct Answer Ask the older brother how he felt during the
incident.
, A pt diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is
scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? -
Correct Answer Allopurinol
A pt in the third trimester of pregnancy reports that she feels some lumpy places in her breasts and that her nipples
sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What actions
should the nurse take? - Correct Answer Explain that this is normal recreation and can be assessed at the next visit.
A pt is admitted with a dx of urolithiasis. Which finding is most important for the nurse to report to the healthcare
provider? - Correct Answer Hematuria that is beginning to turn pink
A pt is dx with Meniere's disease. Which problem should the nurse identify as most important in the plan of care? -
Correct Answer Risk for injury related to vertigo
A pt is receiving enoxaparin 30 mg subcutaneously twice a day. In assessing for adverse effects of the medication,
which serum laboratory value most important for the nurse to monitor - Correct Answer platelet count
A pt is recovering in the critical care unit following a cardiac cath. IV nitro and heparin are infusing. The pt is sedated
but responds to instructions. After changing positions, the pt complains of pain at the right groin insertion site. What
action should the nurse implement? - Correct Answer Stimulate the pt to take deep breaths
A pt is scheduled for a spiral CT scan with contrast to evaluate for pulmonary embolism. Which information in the
client's history requires follow up by the nurse? - Correct Answer take metformin for type 2 diabetes
A pt presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge.
Which action should the nurse take first? - Correct Answer begin continuous fetal monitoring
A pt presses the call bell and requests pain medication for a severe headache. To assess the quality of the pt. Pain,
which approach should the nurse use? - Correct Answer Ask the patient to describe the pain
A pt taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first? - Correct
Answer Observe the appearance of the stool
A pt tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose
weight and sleep better. The pt states that it still is taking hours to fall asleep at night. Which action should the nurse
implement? - Correct Answer Ask the pt for a description of the exercise schedule that is being followed
A pt who gave birth 48 hours ago has decided to bottle feed teh infant. During the assessment, the nurse observes
that both breasts are swollen, warm and tender on palpation. Which instruction should the nurse provide? - Correct
Answer Apply ice to the breast for comfort.
A pt who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the pt, in which
sequence should the nurse complete these actions? - Correct Answer -Observe breathing patterns
-assess blood pressure
-measure body temp
-palpate for pedal edema
A pt who is admitted with complications related to hypopituitarism is diaphoretic and hypotensive. Which assessment
finding warrants immediate intervention by the nurse? - Correct Answer Lethargy
A pt who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about
the procedure. In preparing the pt for the procedure, which intervention has the highest priority? - Correct Answer
Instruct pt to write down questions
A pt with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO every 12hrs. When the
client requests an afternoon snack, which dietary choice should the nurse provide? - Correct Answer Cinnamon apple
sauce
A pt with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse
indicates that the fistula is patient? - Correct Answer Auscultation of a thrill on the left forearm
2 days prior to discharge from the rehab facility, the nurse is teaching a pt who is recovering from Guillain-Barre
syndrome about home. Which actions should the nurse include when providing discharge teaching to the pt and
spouse? SATA - Correct Answer -review safe transfer strategies
-develop a nutritional plan
-help identify community support
A 12 week gestation is admitted to the antepartum unit with a dx of hyperemesis gravidarum. Which action is most
important for the nurse to implement? - Correct Answer initiate prescribed IV fluids
A client fell in the bathroom when left unattended by the UAP. Which information should the nurse include in the pt
health record? - Correct Answer The pt fell sustaining a fracture to the left hip
A client presents to the emergency dept with muscle aches, headache, fever, and describes a recent loss of taste
and smell. The nurse obtains a swab for COVID -19 testing. Which action is most important for the nurse to take? -
Correct Answer place the nasal swab specimen for COVID 19 directly in a biohazard bag.
A client with urge incontinence was treated with onabotulinumtoxinA injections and is now experiencing urinary
retention. Which action should the nurse include in the client's plan of care? - Correct Answer Remind the pt to
practice pelvic floor exercises regularly.
A male client approaches the nurse with an angry expression on his face and raises his voice, saying, "My roommate
is the most selfish, self-centered, angry person I have ever met If he loses his temper one more time with me, I am
going to punch him." The nurse recognizes that the pt is using which defense mechanism? - Correct Answer
Projection
A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at
night with no relief of his discomfort. Which action should the nurse take? - Correct Answer Encourage the pt to use
cooler water and apply calamine lotion after soaking.
A new nurse preparing to irrigate an IV catheter is attaching a 24 gauge needle. Which action should the charge
nurse implement? - Correct Answer Suggest the nurse use 20g needle
A nurse receives a report on a pt who is four hours post-total abdominal hysterectomy. The previous nurse reports
that it was necessary to change the client's perineal pad hourly and that it is again saturated. The previous nurse also
reports that the client's urinary output has decreased. Which action should the nurse implement first? - Correct
Answer Assess for weakness or dizziness
A nurse who is working in the emergency department triage area is presented with four clients at the same time. The
client presenting with which symptoms require the most immediate intervention by the nurse? - Correct Answer Chest
discomfort one hour after consuming a large spicy meal.
A nurse working on an Endocrine Unit should see which client first? - Correct Answer A pt taking corticosteroids who
has become disoriented in the last two hours.
A patient who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several
side effects since taking the med. Which side effect should the nurse report to the healthcare provider? - Correct
Answer Somnambulism
A pediatric client is taking the beta-adrenergic blocking agent propranolol. In developing a teaching plan, the nurse
should teach the parents to report which sign of overdose? - Correct Answer Bradycardia
A preschool aged boy is admitted to the pediatric unit following successful resuscitation from a near drowning
incident. While providing care to the child, the nurse begins with the brother who rescued the child from the swimming
pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what
happened. Which action should the nurse take? - Correct Answer Ask the older brother how he felt during the
incident.
, A pt diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is
scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? -
Correct Answer Allopurinol
A pt in the third trimester of pregnancy reports that she feels some lumpy places in her breasts and that her nipples
sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What actions
should the nurse take? - Correct Answer Explain that this is normal recreation and can be assessed at the next visit.
A pt is admitted with a dx of urolithiasis. Which finding is most important for the nurse to report to the healthcare
provider? - Correct Answer Hematuria that is beginning to turn pink
A pt is dx with Meniere's disease. Which problem should the nurse identify as most important in the plan of care? -
Correct Answer Risk for injury related to vertigo
A pt is receiving enoxaparin 30 mg subcutaneously twice a day. In assessing for adverse effects of the medication,
which serum laboratory value most important for the nurse to monitor - Correct Answer platelet count
A pt is recovering in the critical care unit following a cardiac cath. IV nitro and heparin are infusing. The pt is sedated
but responds to instructions. After changing positions, the pt complains of pain at the right groin insertion site. What
action should the nurse implement? - Correct Answer Stimulate the pt to take deep breaths
A pt is scheduled for a spiral CT scan with contrast to evaluate for pulmonary embolism. Which information in the
client's history requires follow up by the nurse? - Correct Answer take metformin for type 2 diabetes
A pt presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge.
Which action should the nurse take first? - Correct Answer begin continuous fetal monitoring
A pt presses the call bell and requests pain medication for a severe headache. To assess the quality of the pt. Pain,
which approach should the nurse use? - Correct Answer Ask the patient to describe the pain
A pt taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first? - Correct
Answer Observe the appearance of the stool
A pt tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose
weight and sleep better. The pt states that it still is taking hours to fall asleep at night. Which action should the nurse
implement? - Correct Answer Ask the pt for a description of the exercise schedule that is being followed
A pt who gave birth 48 hours ago has decided to bottle feed teh infant. During the assessment, the nurse observes
that both breasts are swollen, warm and tender on palpation. Which instruction should the nurse provide? - Correct
Answer Apply ice to the breast for comfort.
A pt who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the pt, in which
sequence should the nurse complete these actions? - Correct Answer -Observe breathing patterns
-assess blood pressure
-measure body temp
-palpate for pedal edema
A pt who is admitted with complications related to hypopituitarism is diaphoretic and hypotensive. Which assessment
finding warrants immediate intervention by the nurse? - Correct Answer Lethargy
A pt who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about
the procedure. In preparing the pt for the procedure, which intervention has the highest priority? - Correct Answer
Instruct pt to write down questions
A pt with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO every 12hrs. When the
client requests an afternoon snack, which dietary choice should the nurse provide? - Correct Answer Cinnamon apple
sauce
A pt with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse
indicates that the fistula is patient? - Correct Answer Auscultation of a thrill on the left forearm
