HESI PN FUNDAMENTAL NEXTGENERATION EXAM QUESTIONS AND ANSWERS LATEST UPDATE

HESI PN FUNDAMENTAL NEXTGENERATION EXAM QUESTIONS AND ANSWERS LATEST UPDATETerm A 21-year-old female thinks she is pregnant. At the doctor's office, the client asks the nurse, "How reliable is the drugstore pregnancy test." Which of the following identifies the nurse's best response? Choose matching definition "The tests are quite reliable. In order to be sure you are pregnant, I need to get some more information from you." "The test are less reliable than the one the doctor does. We will have to repeat it." "Those kits are not very reliable. Your doctor should make the diagnosis." "They are very reliable. You can be sure you are pregnant." Don't know? 1 of 100 Term Phases of separation anxiety Choose matching definition despair, anxiety, and regression protest, despair, denial denial, dependence, and submission regression, denial, attachment Don't know? 2 of 100 Term The type of female pelvis that is considered the ideal pelvis for a vaginal birth is which of the following? Choose matching definition anthropoid android platypelloid gynecoid Don't know? 3 of 100 Term Invasion of privacy, defamation, assault, battery, false imprisonment Choose matching definition Malpractice Intentional Tort Negligence Res Ipsa Loquitur Don't know? 4 of 100 Term An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? Choose matching definition Position the client on the right side of the bed in reverse Trendelenburg. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. Reposition in a Sim's position with the client's weight on the anterior ilium. Raise the side rails on both sides of the bed and elevate the bed to waist level. Don't know? 5 of 100 Term Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? Choose matching definition Apply a condom catheter. Apply a skin protectant. Encourage increased fluid intake. Assess for bladder distention. Don't know? 6 of 100 Term A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? Choose matching definition Explain that anyone who speaks her language can answer her questions. Provide a translator only in an emergency situation. Ask a family member or friend of the client to translate. Request and document the name of the certified translator. Don't know? 7 of 100 Term normal adult respiratory rate Choose matching definition 15-16 respiration per minutes 14-20 respiration per minutes 19-24 respiration per minutes 4-24 respiration per minutes Don't know? 8 of 100 Term Types of microorganisms include: Choose matching definition behavior motivated by the desire to gain a reward or avoid a negative outcome bacteria, viruses, fungi, protozoa, and rickettsia. a break in the continuity of brain tissue. b. nutritional history. caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (c) should be obtained first so that health teaching can be initiated if indicated. (a and c) can be used for stress management. though (d) can be a source of anxiety, a nutritional history should be obtained first. Don't know? 9 of 100 Term The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? Choose matching definition A college-age track runner with a sprained ankle. A lactating woman nursing her 3-day-old infant. A school-aged child with Type 2 diabetes. An elderly man being treated for a peptic ulcer. Don't know? 10 of 100 Term Which of the following is not generally associated with aging? Choose matching definition Chronic health problems Increased appetite Skin breakdown Reduction in muscle mass Don't know? 11 of 100 Term Which of the following best represents the coloring for granulation tissue? Choose matching definition pink or red clear or white blue or green stays red Don't know? 12 of 100 Term The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? Choose matching definition Talk directly to the child instead of the mother. Continue asking the mother questions about the child. Ask another nurse to interview the mother now. Tell the mother politely to look at you when answering. Don't know? 13 of 100 Term The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? Choose matching definition Observe the appearance of the skin under the ice pack. Instruct the client regarding the need for the covering. Reapply the covering after filling with fresh ice. Ask the client how long the ice was applied to the skin. Don't know? 14 of 100 Term You have a patient who came into the emergency room in great emotional distress saying that she cannot stand to feel the way she does anymore. She says she doesn't sleep well, can't eat, feels hopeless and does not want to go on like this anymore. You know that this patient is in crisis and you also know that after determining that she is not at risk for injury the primary goal in her care is which of the following? Choose matching definition to see that she is provided with the proper medication to get her into a self-help group to encourage her to exercise more to get the patient back to a pre-crisis level of functioning Don't know? 15 of 100 Term When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? Choose matching definition Establish a new nursing diagnosis. Note which actions were not implemented. Add additional nursing orders to the plan. Collaborate with the healthcare provider to make changes. Don't know? 16 of 100 Term An African American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? Choose matching definition Inquire about the source and type of pain. Examine the nose for congestion and discharge. Take vital signs for temperature elevation. Explore the abdominal area for distension Don't know? 17 of 100 Term A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? Choose matching definition In 8 weeks, you will be able to bend at the waist to reach items on the floor. Place a pillow between your knees while lying in bed to prevent hip dislocation. It is safe to use a walker to get out of bed, but you need assistance when walking. Take pain medication 30 minutes after your physical therapy sessions. Don't know? 18 of 100 Term The professional nurse caring for children with increased intracranial pressure is aware that which of the following is NOT personality and behavior signs of this condition? Choose matching definition diminished physical activity and motor performance hallucinations and delusions increased sleeping and drowsiness irritability and restlessness Don't know? 19 of 100 Term The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? Choose matching definition Encourage the client to cough to help loosen secretions. Advise the client to increase the intake of oral fluids. Rotate the suction catheter to obtain any remaining secretions. Re-oxygenate the client before attempting to suction again. Don't know? 20 of 100 Term When caring for a client with venous thrombosis, the nurse understands that the most accurate diagnostic test for venous thrombosis is what? Choose matching definition asculate the lungs asculate the lungs. The best time to asculate the lungs, heart and abdomen of an infant is while the infant is asleep or quiet. During this time, the muscles, such as in the abdomen, are relaxed. Ascending contrast venography The ascending contrast venography uses a contrast medium to assess the location of the venous thrombosis and the extent of the thrombosis. This test is considered the most accurate tool in diagnosing venous thrombosis. The hemoglobin electrophoresis test is used in women of African or Mediterranean descent to identify the presence of the sickle cell trait. Sickle cell anemia is an autosomal disease occurring mainly in African Americans and occasionally in Caucasians of Mediterranean descent. It causes breakdown of red blood cells. A. Loosen the right wrist restraint. The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints). Don't know? 21 of 100 Term At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? Choose matching definition It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. It is OK if you don't want to talk about your surgery. I will be available when you are ready. I will ask a woman who has had a mastectomy to come by and share her experiences with you. Don't know? 22 of 100 Term A nurse who is preparing a patient for eye surgery takes his intraocular pressure. She finds that the pressure in the right eye is 12 mm Hg and the pressure in the left eye is 17 mm Hg. The nurse would tell the patient that: Choose matching definition The pressure in the right eye is low, but the pressure in the left eye is normal. The pressure in both eyes is high. The pressure in both eyes is normal. The pressure in the right eye is normal, but the pressure in the left eye is high. Don't know? 23 of 100 Term When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the: A. Arms. B. Upper torso. C. Head. D. Feet. Choose matching definition C. Reposition in a Sim's position with the client's weight on the anterior ilium. The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned. C. Degree of flexion and extension of the client's knee joint. The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D). B. A decreased flow rate could result in the formation of a thrombosis. Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration. B. Upper torso. The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (B) becoming the center of gravity for older persons. Although (A) is a part, or an extension of the upper torso, this is not the best and most complete answer. Don't know? 24 of 100 Term The nurse understands an infant's posterior fontanel closes within what time period? Choose matching definition 1 - 2 months 2 - 3 months 6 - 12 months 12 - 18 months Don't know? 25 of 100 Term Which theory holds that oxidation releases chemicals that affect the cell membranes and DNA replication? Choose matching definition autoimmune theory cross-linkage theory free-radical theory programmed theory Don't know? 26 of 100 Term Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? Choose matching definition Aspirating gastric contents to assure a pH value of 4 or less. Hearing air pass in the stomach after injecting air into the tubing. Examining a chest x-ray obtained after the tubing was inserted. Checking the remaining length of tubing to ensure that the correct length was inserted. Don't know? 27 of 100 Term During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? Choose matching definition Provide additional coffee on the client's breakfast tray. Exchange the client's grape juice for cranberry juice. Bring the client additional fruit at mid-morning. Encourage additional oral intake of juices and water. Don't know? 28 of 100 Term A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? Choose matching definition demonstrates loss of remote memory. exhibits expressive dysphasia. has a diminished attention span. is disoriented to place and time. Don't know? 29 of 100 Term An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? Choose matching definition A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. The nurse assigned to care for the client who was at lunch at the time of the fall. The nurse who transferred the client to the chair when the fall occurred. The charge nurse who completed rounds 30 minutes before the fall occurred. Don't know? 30 of 100 Term A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? Choose matching definition A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner. Don't know? 31 of 100 Term Which action is most important for the nurse to implement when donning sterile gloves? Choose matching definition Maintain thumb at a ninety degree angle. Hold hands with fingers down while gloving. Keep gloved hands above the elbows. Put the glove on the dominant hand first. Don't know? 32 of 100 Term Sudden onset mutism with bizarre mannerisms and remaining in a stereotyped position with waxy flexibility is a presentation of which of the following types of schizophrenia? Choose matching definition disorganized schizophrenia paranoid schizophrenia catatonic schizophrenia undifferentiated schizophrenia Don't know? 33 of 100 Term Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? Choose matching definition That means you have derived the maximum benefit, and the heat can be removed. Your blood vessels are becoming dilated and removing the heat from the site. We will increase the temperature 5 degrees when the pad no longer feels warm. The body's receptors adapt over time as they are exposed to heat. Don't know? 34 of 100 Term Your patient has had hip replacement surgery. She is being discharged and along with other instructions you advise her not to lift her leg upward from a lying position or elevate the knee when sitting. The primary reason for this is which of the following? Choose matching definition This type of action may cause extreme pain. This type of action will delay healing. This type of action may cause venous thrombosis. This type of action may pop the prosthesis out of the socket. Don't know? 35 of 100 Term A patient comes into the office and is diagnosed with a urinary tract infection. She has had several urinary tract infections over the last couple of years. You go over a teaching plan for her in hopes of preventing further urinary tract infections. Which of the following pieces of advice would NOT be included in your teaching plan? Choose matching definition Fluid intake should be at least 3L/day. Void every 2 to 3 hours during the day. Avoid wearing cotton undergarments. Take prescribed medications. Don't know? 36 of 100 Term In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly: Choose matching definition is to be expected, and progresses with age. often follows relocation to new surroundings. is a result of irreversible brain pathology. can be prevented with adequate sleep. Don't know? 37 of 100 Term The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? Choose matching definition Infuse normal saline at a keep vein open rate. Discontinue the IV and flush the port with heparin. Infuse 10 percent dextrose and water at 54 ml/hr. Obtain a stat blood glucose level and notify the healthcare provider. Don't know? 38 of 100 Term The nurse is assessing a 2-month-old infant. The infant is quiet and is drifting off to sleep. Which of the following should the nurse perform first during the assessment? Choose matching definition an examination of the ear asculate the lungs assess the infant'/s blood pressure palpate the head Don't know? 39 of 100 Term A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? Choose matching definition Assist the ambulating client back to the bed. Encourage the client to ambulate to resolve pneumonia. Obtain a prescription for portable oxygen while ambulating. Move the oximetry probe from the finger to the earlobe Don't know? 40 of 100 Term Distributing HIV brochures and holding a presentation at a health fair is an example of which of the following? Choose matching definition Information dissemination Health risk appraisal and wellness assessment Lifestyle and behavior change Environmental control program Don't know? 41 of 100 Term While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? Choose matching definition Acknowledge that she is supporting the arm correctly. Encourage her to keep the joint covered to maintain warmth. Reinforce the need to grip directly under the joint for better support. Instruct her to grip directly over the joint for better motion. Don't know? 42 of 100 Term A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? Choose matching definition Commend the client for selecting a high biologic value protein. Remind the client that protein in the diet should be avoided. Suggest that the client also select orange juice, to promote absorption. Encourage the client to attend classes on dietary management of CRF. Don't know? 43 of 100 Term An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? Choose matching definition It is important that you continue your medication while learning to meditate. Spiritual meditation requires a time commitment of 15 to 20 minutes daily. Obtain your healthcare provider's permission before starting meditation. Complementary therapy and western medicine can be effective for you. Don't know? 44 of 100 Term An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? Choose matching definition Reaffirm the client's desire for no resuscitative efforts. Transfer the client to a hospice inpatient facility. Prepare the family for the client's impending death. Notify the healthcare provider of the family's request. Don't know? 45 of 100 Term When assessing a patient for alcohol intoxication, all of the following would be supportive of this potential diagnosis EXCEPT: slurred speech heightened reflexes possible hypoglycemia mania decreased respiration Choose matching definition Urinary output of 20 mL/hr A lesser output for 2 consecutive hours would indicate renal insufficiency and should be reported to the physician. A temperature higher than 37.7° C (100.0° F) or lower than 36.1° C (97° F) and a falling blood pressure are immediate concerns and should be reported. Light to moderate serous drainage at a surgical site is expected and should not be reported. C. Keep gloved hands above the elbows. Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D). heightened reflexes mania decreased respiration These are not the usual signs of alcohol intoxication. Instead, reflexes are diminished; depression may be evident; and respiration is increased. Besides the other choices, signs include: drowsiness, tremors, impaired thinking; memory loss; nystagmus; nausea and vomiting; belligerence or grandiosity; and loss of inhibitions. A. Loosen the right wrist restraint. The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints). Don't know? 46 of 100 Term The community center nurse who does health education is conducting what level of prevention? Choose matching definition Primary prevention Secondary prevention Tertiary prevention Focused prevention Don't know? 47 of 100 Term A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? Choose matching definition What is your daily calorie consumption? What vitamin and mineral supplements do you take? Do you feel that you are overweight? Will a clear liquid diet be okay after surgery? Don't know? 48 of 100 Term When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? Choose matching definition Complimentary healing practices interfere with the efficacy of the medical model of treatment. Conventional medications are likely to interact with folk remedies and cause adverse effects. Many complimentary healing practices can be used in conjunction with conventional practices. Conventional medical practices will ultimately replace the use of complimentary healing practices. Don't know? 49 of 100 Term When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? Choose matching definition Loosen the right wrist restraint. Apply a pulse oximeter to the right hand. Compare hand color bilaterally. Palpate the right radial pulse. Don't know? 50 of 100 Term A client who has a menstrual period more than 35 days a part correlates with which of the following conditions: Choose matching definition hypomenorrhea menorrhagia metrorrhagia oligomenorrhea Don't know? 51 of 100 Term A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? Choose matching definition Contact the healthcare provider and complete a medication variance form. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. Notify the charge nurse and complete an incident report to explain the missed dose. Give the missed dose at 1300 and change the schedule to administer daily at 1300. Don't know? 52 of 100 Term Which of the following tests is used to identify the presence of the sickle cell trait? Choose matching definition dry skin poor skin turgor increased urine output These are things related to fluid deficit rather than fluid excess. Fluid excess is associated with heart and kidney disease. It is observed as edema, weight gain, and reduced urine output. The hemoglobin electrophoresis test is used in women of African or Mediterranean descent to identify the presence of the sickle cell trait. Sickle cell anemia is an autosomal disease occurring mainly in African Americans and occasionally in Caucasians of Mediterranean descent. It causes breakdown of red blood cells. pink or shiny refraction deflection These are not therapeutic communication techniques. In addition to the other two choices, therapeutic communication techniques include: listening, restating, clarification, reflection, humor, focusing, sharing perceptions, theme identification, suggesting, and silence. Don't know? 53 of 100 Term A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? Choose matching definition Obtain the pre-transfusion hemoglobin level. Prime the tubing and prepare a blood pump set-up. Monitor vital signs q15 minutes for the first hour. Ensure the accuracy of the blood type match. Don't know? 54 of 100 Term The nurse asks the newly pregnant woman if she has a cat as a pet. Which of the following reasons best explains why the nurse asks about pets? Choose matching definition Cats may suffocate new babies and should not be in the home when a baby arrives. Cat feces may cause toxoplasmosis, which can lead to blindness, brain defects, and stillbirth. Cats are jealous of babies and may try to kill them during infancy. If the mother gets scratched by a cat, the baby may develop heart defects. Don't know? 55 of 100 Term Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? Choose matching definition Chocolate pudding. Graham crackers. Sugar free gelatin. Apple slices. Don't know? 56 of 100 Term A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? Choose matching definition Administer the medication more rapidly using the same IV site. Initiate an alternate site for the IV infusion of the medication. Notify the healthcare provider before administering the next dose. Give the client a PRN dose of aspirin while the medication infuses. Don't know? 57 of 100 Term An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? Choose matching definition Massage any reddened areas for at least five minutes. Encourage active range of motion exercises on extremities. Position the client laterally, prone, and dorsally in sequence. Gently lift the client when moving into a desired position. Don't know? 58 of 100 Term cerebral laceration Choose matching definition a condition where brain cells regenerate rapidly a break in the continuity of brain tissue. an inflammation of the protective membranes surrounding the brain a type of brain tumor that affects cognitive functions Don't know? 59 of 100 Term Medicare Part D Choose matching definition Physician services Hospital insurance What to do if a dose is missed Prescription drug coverage Don't know? 60 of 100 Term At three hours after the birth of a newborn, the nurse should expect which of the following for the infant's respirations? Choose matching definition dry skin poor skin turgor increased urine output These are things related to fluid deficit rather than fluid excess. Fluid excess is associated with heart and kidney disease. It is observed as edema, weight gain, and reduced urine output. irregular and between 30 to 60 per minute Vital signs that are assessed within the first 4 hours of an neonate's birth should include blood pressure as needed, temperature, respirations and pulse, which is monitored every hour for the first four hours unless there is distress that warrants more frequent monitoring. The respirations for a newborn is between 30 to 60 per minute and they are irregular. a puzzle with large pieces. At age 4, children like to color, draw, and put together puzzles. A bicycle is appropriate for a 5 or 6 year old child, a pull toy for a toddler and a computer game for a school age child. is elevated and may indicate inflammation The normal range for the white blood cell count (WBC) is between 4,300 to 10,800mm3. The client has a WBC of 30,000/mm3 which is outside of the normal range and is elevated. With some disorders such as appendicitis, which is an inflammatory disease, the WBC count is elevated. Don't know? 61 of 100 Term If you are combing the hair of a patient who is unable to do so, you would know all of the following EXCEPT: If hair is tangled, use 95% alcohol for dry hair. Start at the ends, working toward the scalp. Hold hair close to head to prevent pulling. Use mineral oil for oily hair to untangle. Comb or brush the hair daily to avoid tangles. Choose matching definition This type of action may pop the prosthesis out of the socket. This question asks for the primary reason for this advice. The primary reason is that this type of action may pop the prosthesis out of the socket. If hair is tangled, use 95% alcohol for dry hair. Use mineral oil for oily hair to untangle. For tangles, you would use 95% alcohol for oily hair. You would use mineral oil for dry hair. Shampoo as often as necessary and as patient's condition permits. hallucinations and delusions The behavior signs include inability to follow simple commands, decline in school performance, lethargy, indifference, and the answers (a, c, and d). Hallucinations and delusions are not included in the list. A. Inquire about the source and type of pain. Different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as "the miseries. " Based on understanding this term, the nurse should conduct a focused assessment on the source and type of pain (A). (B, C, and D) are important, but do not focus on "miseries" (pain). Don't know? 62 of 100 Term A 50 year old client has abdominal pain in the lower quadrant of the abdomen. The client's WBC shows 30,000/mm3. The nurse understands the WBC count: Choose matching definition is within the normal range indicates a metabolic disorder is elevated and may indicate inflammation is consistent with metabolic distress Don't know? 63 of 100 Term Medicare Part A Choose matching definition physician services hospital coverage medical insurance hospital insurance Don't know? 64 of 100 Term One minute after birth, the physician rates a newborn infant on five factors. Which of the following is not one of those factors? Choose matching definition appearance pulse temperature grimace Don't know? 65 of 100 Term The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? Choose matching definition The belief is held that the "evil eye" enters the child if anything cold is ingested. After surgery the child probably has refused all foods except broth. Eating broth strengthens the child's innate energy called "chi." Hot remedies restore balance after surgery, which is considered a "cold" condition. Don't know? 66 of 100 Term A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? Choose matching definition Give an around-the-clock schedule for administration of analgesics. Administer analgesic medication as needed when the pain is severe. Provide medication to keep the client sedated and unaware of stimuli. Offer a medication-free period so that the client can do daily activities. Don't know? 67 of 100 Term Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? Choose matching definition Reassure the client that he will become accustomed to the stoma appearance in time. Instruct the client that the stoma will become smaller when the initial swelling diminishes. Offer to contact a member of the local ostomy support group to help him with his concerns. Encourage the client to handle the stoma equipment to gain confidence with the procedure. Don't know? 68 of 100 Term During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? Choose matching definition Request another nurse to complete the physical assessment. Ask the client to stop crying and tell the nurse what is wrong. Acknowledge the client's distress and tell her it is all right to cry. Leave the room so that the client can be alone to cry in private. Don't know? 69 of 100 Term Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? Choose matching definition Height in inches or centimeters. Weight in kilograms or pounds. Triceps skin fold thickness. Upper arm circumference. Don't know? 70 of 100 Term There are a number of sociological theories that have been put forth about the aging process. Which of the following is NOT a part of the theory of disengagement? The person remains active and interacts with society and its events. It supports leisure as a form of activity. Lifelong coping strategies continue. There is a mutual withdrawal from social interaction by older adult and society. Choose matching definition The pressure in both eyes is normal. In this patient's case the pressure is normal in both eyes. Normal intraocular pressure ranges from 8 mm Hg to 21 mm Hg. The person remains active and interacts with society and its events. Lifelong coping strategies continue. These are not part of the theory of disengagement. This theory is controversial. It describes engagement as active occupation and devotion and respects individually-initiated withdrawal. B. Fowler's. The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration. A. Observe the appearance of the skin under the ice pack. The first action taken by the nurse should be to assess the skin for any possible thermal injury (A). If no injury to the skin has occurred, the nurse can take the other actions (B, C, and D) as needed. Don't know? 71 of 100 Term Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? Choose matching definition Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. Don't know? 72 of 100 Term What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? Choose matching definition It is more difficult to find a superficial vein in the feet and ankles. A decreased flow rate could result in the formation of a thrombosis. A cannulated extremity is more difficult to move when the leg or foot is used. Veins are located deep in the feet and ankles, resulting in a more painful procedure. Don't know? 73 of 100 Term Normal range for serum potassium Choose matching definition Prescription drug coverage pink or red a break in the continuity of brain tissue. 3.5-5.0 mEq/L Don't know? 74 of 100 Term A female client is discharged from the hospital post delivery. The nurse escorts a mother and her newborn to the car. Which of the following approaches should the nurse instruct the new mother to place the newborn? Choose matching definition in the mother's lap with the seat beat across both the mother and the baby on the front passenger side with the car seat facing forward in the back seat of the car with the car seat facing backwards in the middle section of the backseat with the baby positioned in the car seat facing forward Don't know? 75 of 100 Term A PN in the postoperative department has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which of the following parameters most carefully during the next hour? Choose matching definition temperature of 37.6° C (99.6° F) blood pressure of 100/70 mm Hg serous drainage on the surgical dressing urinary output of 20 mL/hr Don't know? 76 of 100 Term Which toy would be most appropriate for a 4-year-old? Choose matching definition a bicycle a puzzle with large pieces a pull toy a computer game Don't know? 77 of 100 Term A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? Choose matching definition Sexual activity patterns. Nutritional history. Leisure activities. Financial stressors. Don't know? 78 of 100 Term A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client: Choose matching definition asks relevant questions regarding the dressing change. states he will be able to complete the wound care regimen. demonstrates the wound care procedure correctly. has all the necessary supplies for wound care. Don't know? 79 of 100 Term A patient who is almost 39 weeks pregnant comes to your office with uterine contractions that are mild and infrequent. The doctor orders a sonogram to determine the amniotic fluid index (AFI). Which of the following results would cause concern? Choose matching definition 4.5 6.0 7.5 10.5 Don't know? 80 of 100 Term A client is scheduled for a dilation and curettage. The nurse instructs the client to come in a day before the scheduled procedure for the insertion of laminaria. The main reason for the laminaria insertion is to: Choose matching definition prevent hemorrhaging dilate the cervix promote wound healing promote vaginal blood circulation Don't know? 81 of 100 Term Which of the following would indicate that a person is in a pre-diabetic stage? fasting blood glucose is 150 mg/dL fasting blood glucose is 110 mg/dL postprandial blood glucose is 110 mg/dL postprandial blood glucose is 130 mg/dL fasting blood glucose is 118 mg/dL Choose matching definition Ascending contrast venography The ascending contrast venography uses a contrast medium to assess the location of the venous thrombosis and the extent of the thrombosis. This test is considered the most accurate tool in diagnosing venous thrombosis. refraction deflection These are not therapeutic communication techniques. In addition to the other two choices, therapeutic communication techniques include: listening, restating, clarification, reflection, humor, focusing, sharing perceptions, theme identification, suggesting, and silence. D. Assess for bladder distention. Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder distention. fasting blood glucose is 110 mg/dL fasting blood glucose is 118 mg/dL Prediabetes can occur when the fasting blood glucose is greater than 100 mg/dL and less than 126 mg/dL or when postprandial blood glucose is greater than 140 mg/dL and less than 200 mg/dL. Fasting blood glucose levels of 110 mg/dL and 118 mg/dL are therefore pre-diabetic. Don't know? 82 of 100 Term The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? Choose matching definition Place the chair at a right angle to the bed on the client's left side before moving. Assist the client to a standing position, then place the right hand on the armrest. Have the client place the left foot next to the chair and pivot to the left before sitting. Move the chair parallel to the right side of the bed and stand the client on the right foot. Don't know? 83 of 100 Term An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? Choose matching definition Prone. Fowler's. Sims'. Supine. Don't know? 84 of 100 Term The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? Choose matching definition Thalamus. Hypothalamus. Frontal lobe. Parietal lobe. Don't know? 85 of 100 Term A pregnant woman who is having true rather than false contractions will experience all of the following EXCEPT: Choose matching definition contractions that lessen with activity or rest discomfort that radiates from the back around to the abdomen contractions that are regular with increasing frequency cervix that is progressively effaced and dilated Don't know? 86 of 100 Term The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? Choose matching definition Tell the UAP to use a larger cuff at the next scheduled assessment. Reassess the client's blood pressure using a larger cuff. Have the unit educator review this procedure with the UAPs. Teach the UAP the correct technique for assessing blood pressure. Don't know? 87 of 100 Term The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? Choose matching definition Clamp the tube for 20 minutes. Flush the tube with water. Administer the medications as prescribed. Crush the tablets and dissolve in sterile water. Don't know? 88 of 100 Term After completing an assessment and determining that a client has a problem, which action should the nurse perform next? Choose matching definition Determine the etiology of the problem. Prioritize nursing care interventions. Plan appropriate interventions. Collaborate with the client to set goals. Don't know? 89 of 100 Term Which of the following best represents the coloring for epithelial tissue? Choose matching definition this type of action may pop the prosthesis out of the socket. this question asks for the primary reason for this advice. the primary reason is that this type of action may pop the prosthesis out of the socket. free-radical theory pink or shiny yellow or white Don't know? 90 of 100 Term A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the nurse to take? Choose matching definition Record the coughing incident. No further action is required at this time. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. Don't know? 91 of 100 Term During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? Choose matching definition Adequate venous blood flow to the lower extremities. Estimated amount of body fat by an underarm skinfold. Degree of flexion and extension of the client's knee joint. Change in the circumference of the joint in centimeters. Don't know? 92 of 100 Term The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? Choose matching definition The client voluntarily signed the form. The client fully understands the procedure. The client agrees with the procedure to be done. The client authorizes continued treatment. Don't know? 93 of 100 Term A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? Choose matching definition Ask about any past history of drug abuse or addiction. Measure the pulse volume and capillary refill distal to the infiltration. Compress the infiltrated tissue to measure the degree of edema. Evaluate the extent of ecchymosis over the forearm area. Don't know? 94 of 100 Term Which of the following best represents the coloring for necrotic tissue? Choose matching definition d. move the chair parallel to the right side of the bed and stand the client on the right foot. (d) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (a, b, and c) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver. black, brown, or tan yellow or white Yellow or White Don't know? 95 of 100 Term The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? Choose matching definition Tossed salad, low-sodium dressing, bacon and tomato sandwich. New England clam chowder, no-salt crackers, fresh fruit salad. Skim milk, turkey salad, roll, and vanilla ice cream. Macaroni and cheese, diet Coke, a slice of cherry pie. Don't know? 96 of 100 Term Medicare Part B Choose matching definition Medical and surgical Physician services Prescription drug coverage Hospital insurance