HESI RN COMPREHENSIVE EXIT EXAM VERSION VII- 160+ QUESTIONS AND ANSWERS
WITH RATIONALES|WELL STRUCTURED|A+ GRADED|
QUESTIONS ANSWERS
A male client is admitted for the removal of an internal fixation that a. Collect multiple site screening culture for MRSA
was inserted for the fracture ankle. During the admission history, c. Place the client on contact transmission precautions
he tells the nurse he recently received vancomycin (vancomycin) e. Continue to monitor for client sign of infection.
for a methicillin-resistant Staphylococcus aureus (MRSA) wound
infection. Which action should the nurse take? (Select all that Rationale: Until multi-site screening cultures come back negative
apply.) (A), the client should be maintained on contact isolation(C) to
minimize the risk for nosocomial infection. Linezolid (Zyvox), a
a. Collect multiple site screening culture for MRSA broad spectrum anti-infecting, is not indicated, unless the client
b. Call healthcare provider for a prescription for linezolid (Zyrovix) has an active skin structure infection cause by MRSA or multidrug-
c. Place the client on contact transmission precautions resistant strains (MDRSP) of Staphylococcus aureus. A sputum
d. Obtain sputum specimen for culture and sensitivity culture is not indicated D) based on the client's history is a wound
e. Continue to monitor for client sign of infection. infection.
Ensure the transparent dressing has no tears that might create
A vacuum-assistive closure (VAC) device is being use to provide vacuum leak
wound care for a client who has stage III pressure ulcer on a
below-the- knee (BKA) residual limb. Which intervention should Rationale: The nurse should ensure that the VAC transparent film
the nurse implement to ensure maximum effectiveness of the is intact, without tears or loose edges C) because a break in the
device? seal resulting in drying the wound and decreasing the vacuum.
The vacuum-assisted closure (VAC) device uses an open sponge
a. Empty the device every 8 hours and change the dressing daily in the wound bed, sealed with a transparent film dressing and
ensure sterility tube extrudes to a suction device that exert negative pressure
b. Extended the transparent film dressing only to edge of wound to remove excess wound fluid, reduce the bacterial count and
to prevent tension. stimulate granulation. The VAC is changed every other day or
c. Ensure the transparent dressing has no tears that might create third day, not (A) depending on the stage of wound healing and
vacuum leaks emptied when full or weekly. The transparent wound dressing
d. Use an adhesive remover when changing the dressing to pro- should extend 3 to 5 cm beyond the wound edges, not (B) to
mote comfort. ensure and airtight seal. Adhesive removers leave a reduce that
binder transparent film adherence (D)
The nurse is developing the plan of care for a client with pneumo-
Increase fluid intake to 3,000 ml/daily
nia and includes the nursing diagnosis of "Ineffective airway clear-
ance related to thick pulmonary secretions." Which intervention is
Rationale: The plan of care should include an increase in fluid
most important for the nurse to include in the client's plan of care?
intake (A) to liquefy and thin secretions for easier removal of thick
a. Increase fluid intake to 3,000 ml/daily pulmonary secretion which facilitates airway clearance. (B) should
be implemented for signs of hypoxia (C) implemented to facilitate
b. Administer O2 at 5L/mint per nasal cannula
lung expansion, and (D) implemented for activity intolerance, but
c. Maintain the client in a semi Fowler's position
these interventions do not have the priority of (A)
d. Provide frequent rest period.
The nurse plans to collect a 24- hour urine specimen for a creati-
nine clearance test. Which instruction should the nurse provide to
the adult male client?
Urinate at specific time, discard the urine, and collect all subse-
quent urine during the next 24 hours.
a. Clearance around the meatus, discard first portion of voiding,
and collect the rest in a sterile bottle
Rationale: Urinate at specific time, discard the urine, and collect all
b. Urinate at specific time, discard the urine, and collect all sub-
subsequent urine during the next 24 hours is the correct procedure
sequent urine during the next 24 hours.
for collecting 24-hour urine specimen. Discarding even one voided
c. For the next 24 hours, notify the nurse when the bladder is full, specimen invalidate the test.
and the nurse will collect catheterized specimens.
d. Urinate immediately into a urinal, and the lab will collect spec-
imen every 6 hours, for the next 24 hours.
The nurse is preparing to administer a histamine 2-receptor an-
tagonist to a client with peptic ulcer disease. What is the primary
purpose of this drug classification?
Decreases the amount of HCL secretion by the parietal cells in the
stomach
a. Neutralize hydrochloric (HCI) acid in the stomach
b. Decreases the amount of HCL secretion by the parietal cells in
Rationale: B correctly describe the action of histamine 2 receptor
the stomach
antagonist in helping to prevent peptic ulcer disease.
c. Inhibit action of acetylcholine by blocking parasympathetic
nerve endings.
d. Destroys microorganisms causing stomach inflammation.
The healthcare provider prescribes acarbose (Precose), an al- Hemoglobin A1C (HbA1C) reading less than 7%
pha-glucosidase inhibitor, for a client with Type 2 diabetes mel-
, HESI RN COMPREHENSIVE EXIT EXAM VERSION VII- 160+ QUESTIONS AND ANSWERS
WITH RATIONALES|WELL STRUCTURED|A+ GRADED|
QUESTIONS ANSWERS
litus. Which information provides the best indicator of the drug's Rationale: Acarbose (Precose) delays carbohydrate absorption in
effectiveness? the GI tract and causes the blood glucose to rise slowly after
a meal. The best indicator of acarbose effectiveness is a serum
a. Body max index (BMI) between 20 and 24 hemoglobin A1 no greater than 7%, an indication of glucose level
b. Blood pressure reading less than 120/80 mm Hg over time. Acarbose has no effect on pain or blood pressure.
c. Hemoglobin A1C (HbA1C) reading less than 7% Self-reported glucose levels of 120-150 reflect the blood sugar at
d. Self-reported glucose levels of 120-150 mg/dl. the time taken and are not the best indicator of drug effectiveness.
The nurse assesses a client with new onset diarrhea. It is most
important for the nurse to question the client about recent use of Antibiotics
which type of medication?
Rationale: Antibiotic use may be altering the normal flora in the
a. Antibiotics GI tract, resulting in the onset of diarrhea, and several classes of
b. Anticoagulants antibiotics result in the overgrowth of Clostridium difficile, resulting
c. Antihypertensive in severe diarrhea.
d. Anticholinergics
a. Give O2 at 6 L/nasal canula for 3 repeated oximetry screens
below 90%
A neonate with a congenital heart defect (CHD) is demonstrating
c. Evaluate heart rate for effectiveness of cardio tonic medications
symptoms of heart failure (HF). Which interventions should the
d. Use high energy formula 30 calories/ounce at Q3 hours feeding
nurse include in the infant's plan of care?
via soft nipples
e. Ensure uninterrupted and frequent rest periods between proce-
a. Give O2 at 6 L/nasal canula for 3 repeated oximetry screens
dures.
below 90%
b. Administer diuretics via secondary infusion in the morning only Rationale: Pulse oximetry screening supports prescribed level
c. Evaluate heart rate for effectiveness of cardio tonic medications
d. Use high energy formula 30 calories/ounce at Q3 hours feeding of O2. HR provides an evaluative criterion for cardiac medica-
tions, which reduce heart rate, increase strength contractions
via soft nipples
(inotropic effects) and consequently affect systemic circulation
e. Ensure uninterrupted and frequent rest periods between pro-
and tissue oxygenation. Breast milk or basic formula provide 20
cedures.
calories/ounce, so frequent feedings with high energy formula. D
minimize fatigue is necessary.
1. Start chest compressions with assisted manual ventilations
2. Administer epinephrine 0.01 mg/kg intraosseous (IO)
The nurse is caring for a 4-year-old male child who becomes 3. Apply pads and prepare for transthoracic pacing
unresponsive as his heart rate decreases to 40 beats/minute. 4. Review the possible underlying causes for bradycardia
His blood pressure is 88/70 mmHg, and his oxygen saturation is
70% while receiving 100% oxygen by non-rebreather face mask. Rationale: The American Heart Association guidelines recom-
In what sequence, from first to last, should the nurse implement mend that the basic life support (BLS) algorithm should be initiated
these actions? (Place the first action on top and last action on the immediately in pediatric clients who are unresponsive or have a
bottom.) heart rate below 60 beats/minutes*** and exhibit signs of poor
perfusion. This child is manifesting poor perfusion as evidenced
1. Start chest compressions with assisted manual ventilations by a low blood pressure and poor oxygenation, so chest com-
2. Administer epinephrine 0.01 mg/kg intraosseous (IO) pression and assisted manual ventilation should be provided first,
3. Apply pads and prepare for transthoracic pacing followed by administration of drug therapy for persistent brady-
4. Review the possible underlying causes for bradycardia. cardia. Preparation with pad placement for transthoracic pacing
should be implemented next, followed by treatment indicated for
the underlying cause of the child's bradycardia.
An elderly male client is admitted to the mental health unit with
a sudden onset of global disorientation and is continuously con-
versing with his mother, who died 50 years ago.The nurse reviews
the multiple prescriptions he is currently taking and assesses Delirium
his urine specimen, which is cloudy, dark yellow, and has foul
odor. These findings suggest that his client is experiencing which Rationale: The client's clinical findings-polypharmia, urinary tract
condition? infection, and possible fluid imbalance are the most common
causes of cognition and memory impairment, which is character-
a. Delirium istic of delirium.
b. Depression
c. Dementia
d. Psychotic episode
Following an esophagogastroduodenoscopy (EGD) a male client
a. Prepare medication reversal agent
is drowsy and difficult to arouse, and his respiration are slow and
b. Check oxygen saturation level
shallow. Which action should the nurse implement? Select all that
, HESI RN COMPREHENSIVE EXIT EXAM VERSION VII- 160+ QUESTIONS AND ANSWERS
WITH RATIONALES|WELL STRUCTURED|A+ GRADED|
QUESTIONS ANSWERS
apply. c. Apply oxygen via nasal cannula
a. Prepare medication reversal agent Rationale: Sedation, given during the procedure may need to be
b. Check oxygen saturation level reverse if the client does not easily wake up. Oxygen saturation
c. Apply oxygen via nasal cannula level should be asses, and oxygen applied to support respiratory
d. Initiate bag- valve mask ventilation. effort and oxygenation. The client is still breathing so the bag-
e. Begin cardiopulmonary resuscitation valve mask ventilation and CPR are not necessary.
The nurse is planning preoperative teaching plan of a 12-years
old child who is scheduled for surgery. To help reduce the child
anxiety, which action is the best for the nurse to implement? Provide a family tour of the preoperative unit one week before the
surgery is scheduled
a. Give the child syringes or hospital mask to play it at home prior
to hospitalization. Rationale: School age children gain satisfaction from exploring
b. Include the child in pay therapy with children who are hospital- and manipulating their environment, thinking about objectives,
ized for similar surgery. situations and events, and making judgments based on what they
c. Provide a family tour of the preoperative unit one week before reason. A tour of the unit allows the child to see the hospital
the surgery is scheduled. environment and reinforce explanation and conceptual thinking.
d. Provide doll an equipment to re-enact feeling associated with
painful procedures
Assess IV site frequently for signs of extravasation
Which intervention should the nurse implement during the admin-
istration of vesicant chemotherapeutic agent via an IV site in the
client's arm? Rationale: Infiltration of a vesicant can cause severe tissue dam-
age and necrosis, so the IV site should be assessed regularly for
a. Explain the temporary burning of the IV site may occur. extravasation (B) of the chemotherapeutic agent.The client should
b. Assess IV site frequently for signs of extravasation be instructed to report any discomfort at the site (A). If pain and
c. Apply a topical anesthetic of the infusion site for burning burning occur, the IV should be stopped and C is not indicated.
d. Monitor capillary refill distal to the infusion site. Peripheral pulses, not D, provide the best assessment of perfusion
distal to the infusion should the drug extravasate or infiltrate.
When development a teaching plan for a client newly diagnosed
Give a dose of regular insulin per sliding scale
type 1 diabetes, the nurse should explain that an increase thirst is
an early sing of diabetes ketoacidosis (DKA), which action should
Rationale: As hyperglycemia persist, ketone body become a fuel
the nurse instruct the client to implement if this sign of DKA occur? source, and the client manifest early signs of DKA that include
excessive thirst, frequent urination, headache, nausea and vom-
a. Resume normal physical activity
iting. Which result in dehydration and loss of electrolyte. The client
b. Drink electrolyte fluid replacement
should determine fingerstick glucose level and self-administer a
c. Give a dose of regular insulin per sliding scale
dose of regular insulin per sliding scale.
d. Measure urinary output over 24 hours.
The nurse is teaching a group of clients with rheumatoid arthritis
about the need to modify daily activities. Which goal should the
nurse emphasize? a. Protect joint function
a. Protect joint function Rationale: Primary goal in the management of rheumatoid arthritis
b. Improve circulation is to protect and maintain joint function.
c. Control tremors
d. Increase weight bearing.
An adult client experiences a gasoline tank fire when riding a
motorcycle and is admitted to the emergency department (ED)
36%
with full thickness burns to all surfaces of both lower extremities.
What percentage of body surface area should the nurse document
Rational: according to the rule of nines, the anterior and posterior
in the electronic medical record (EMR)?
surfaces of one lower extremity is designated as 18 %of total body
surface area (TBSA), so both extremities equal 36% TBSA, other
36
options are incorrect.
(1 total leg front/back = 18, 1 total arm front/back = 9, torso = 18,
back = 18, head = 9, pubic = 1 = 100%)
A client with hyperthyroidism is receiving propranolol (Inderal). Decrease in pulse rate
Which finding indicates that the medication is having the desired
effect Rationale: Beta blockers such as propranolol help control the
symptoms of hyperthyroidism, such as palpitations or tachycardia,
a. Decrease in serum T4 levels but do not alter thyroid hormone levels, B is not a desired effect
WITH RATIONALES|WELL STRUCTURED|A+ GRADED|
QUESTIONS ANSWERS
A male client is admitted for the removal of an internal fixation that a. Collect multiple site screening culture for MRSA
was inserted for the fracture ankle. During the admission history, c. Place the client on contact transmission precautions
he tells the nurse he recently received vancomycin (vancomycin) e. Continue to monitor for client sign of infection.
for a methicillin-resistant Staphylococcus aureus (MRSA) wound
infection. Which action should the nurse take? (Select all that Rationale: Until multi-site screening cultures come back negative
apply.) (A), the client should be maintained on contact isolation(C) to
minimize the risk for nosocomial infection. Linezolid (Zyvox), a
a. Collect multiple site screening culture for MRSA broad spectrum anti-infecting, is not indicated, unless the client
b. Call healthcare provider for a prescription for linezolid (Zyrovix) has an active skin structure infection cause by MRSA or multidrug-
c. Place the client on contact transmission precautions resistant strains (MDRSP) of Staphylococcus aureus. A sputum
d. Obtain sputum specimen for culture and sensitivity culture is not indicated D) based on the client's history is a wound
e. Continue to monitor for client sign of infection. infection.
Ensure the transparent dressing has no tears that might create
A vacuum-assistive closure (VAC) device is being use to provide vacuum leak
wound care for a client who has stage III pressure ulcer on a
below-the- knee (BKA) residual limb. Which intervention should Rationale: The nurse should ensure that the VAC transparent film
the nurse implement to ensure maximum effectiveness of the is intact, without tears or loose edges C) because a break in the
device? seal resulting in drying the wound and decreasing the vacuum.
The vacuum-assisted closure (VAC) device uses an open sponge
a. Empty the device every 8 hours and change the dressing daily in the wound bed, sealed with a transparent film dressing and
ensure sterility tube extrudes to a suction device that exert negative pressure
b. Extended the transparent film dressing only to edge of wound to remove excess wound fluid, reduce the bacterial count and
to prevent tension. stimulate granulation. The VAC is changed every other day or
c. Ensure the transparent dressing has no tears that might create third day, not (A) depending on the stage of wound healing and
vacuum leaks emptied when full or weekly. The transparent wound dressing
d. Use an adhesive remover when changing the dressing to pro- should extend 3 to 5 cm beyond the wound edges, not (B) to
mote comfort. ensure and airtight seal. Adhesive removers leave a reduce that
binder transparent film adherence (D)
The nurse is developing the plan of care for a client with pneumo-
Increase fluid intake to 3,000 ml/daily
nia and includes the nursing diagnosis of "Ineffective airway clear-
ance related to thick pulmonary secretions." Which intervention is
Rationale: The plan of care should include an increase in fluid
most important for the nurse to include in the client's plan of care?
intake (A) to liquefy and thin secretions for easier removal of thick
a. Increase fluid intake to 3,000 ml/daily pulmonary secretion which facilitates airway clearance. (B) should
be implemented for signs of hypoxia (C) implemented to facilitate
b. Administer O2 at 5L/mint per nasal cannula
lung expansion, and (D) implemented for activity intolerance, but
c. Maintain the client in a semi Fowler's position
these interventions do not have the priority of (A)
d. Provide frequent rest period.
The nurse plans to collect a 24- hour urine specimen for a creati-
nine clearance test. Which instruction should the nurse provide to
the adult male client?
Urinate at specific time, discard the urine, and collect all subse-
quent urine during the next 24 hours.
a. Clearance around the meatus, discard first portion of voiding,
and collect the rest in a sterile bottle
Rationale: Urinate at specific time, discard the urine, and collect all
b. Urinate at specific time, discard the urine, and collect all sub-
subsequent urine during the next 24 hours is the correct procedure
sequent urine during the next 24 hours.
for collecting 24-hour urine specimen. Discarding even one voided
c. For the next 24 hours, notify the nurse when the bladder is full, specimen invalidate the test.
and the nurse will collect catheterized specimens.
d. Urinate immediately into a urinal, and the lab will collect spec-
imen every 6 hours, for the next 24 hours.
The nurse is preparing to administer a histamine 2-receptor an-
tagonist to a client with peptic ulcer disease. What is the primary
purpose of this drug classification?
Decreases the amount of HCL secretion by the parietal cells in the
stomach
a. Neutralize hydrochloric (HCI) acid in the stomach
b. Decreases the amount of HCL secretion by the parietal cells in
Rationale: B correctly describe the action of histamine 2 receptor
the stomach
antagonist in helping to prevent peptic ulcer disease.
c. Inhibit action of acetylcholine by blocking parasympathetic
nerve endings.
d. Destroys microorganisms causing stomach inflammation.
The healthcare provider prescribes acarbose (Precose), an al- Hemoglobin A1C (HbA1C) reading less than 7%
pha-glucosidase inhibitor, for a client with Type 2 diabetes mel-
, HESI RN COMPREHENSIVE EXIT EXAM VERSION VII- 160+ QUESTIONS AND ANSWERS
WITH RATIONALES|WELL STRUCTURED|A+ GRADED|
QUESTIONS ANSWERS
litus. Which information provides the best indicator of the drug's Rationale: Acarbose (Precose) delays carbohydrate absorption in
effectiveness? the GI tract and causes the blood glucose to rise slowly after
a meal. The best indicator of acarbose effectiveness is a serum
a. Body max index (BMI) between 20 and 24 hemoglobin A1 no greater than 7%, an indication of glucose level
b. Blood pressure reading less than 120/80 mm Hg over time. Acarbose has no effect on pain or blood pressure.
c. Hemoglobin A1C (HbA1C) reading less than 7% Self-reported glucose levels of 120-150 reflect the blood sugar at
d. Self-reported glucose levels of 120-150 mg/dl. the time taken and are not the best indicator of drug effectiveness.
The nurse assesses a client with new onset diarrhea. It is most
important for the nurse to question the client about recent use of Antibiotics
which type of medication?
Rationale: Antibiotic use may be altering the normal flora in the
a. Antibiotics GI tract, resulting in the onset of diarrhea, and several classes of
b. Anticoagulants antibiotics result in the overgrowth of Clostridium difficile, resulting
c. Antihypertensive in severe diarrhea.
d. Anticholinergics
a. Give O2 at 6 L/nasal canula for 3 repeated oximetry screens
below 90%
A neonate with a congenital heart defect (CHD) is demonstrating
c. Evaluate heart rate for effectiveness of cardio tonic medications
symptoms of heart failure (HF). Which interventions should the
d. Use high energy formula 30 calories/ounce at Q3 hours feeding
nurse include in the infant's plan of care?
via soft nipples
e. Ensure uninterrupted and frequent rest periods between proce-
a. Give O2 at 6 L/nasal canula for 3 repeated oximetry screens
dures.
below 90%
b. Administer diuretics via secondary infusion in the morning only Rationale: Pulse oximetry screening supports prescribed level
c. Evaluate heart rate for effectiveness of cardio tonic medications
d. Use high energy formula 30 calories/ounce at Q3 hours feeding of O2. HR provides an evaluative criterion for cardiac medica-
tions, which reduce heart rate, increase strength contractions
via soft nipples
(inotropic effects) and consequently affect systemic circulation
e. Ensure uninterrupted and frequent rest periods between pro-
and tissue oxygenation. Breast milk or basic formula provide 20
cedures.
calories/ounce, so frequent feedings with high energy formula. D
minimize fatigue is necessary.
1. Start chest compressions with assisted manual ventilations
2. Administer epinephrine 0.01 mg/kg intraosseous (IO)
The nurse is caring for a 4-year-old male child who becomes 3. Apply pads and prepare for transthoracic pacing
unresponsive as his heart rate decreases to 40 beats/minute. 4. Review the possible underlying causes for bradycardia
His blood pressure is 88/70 mmHg, and his oxygen saturation is
70% while receiving 100% oxygen by non-rebreather face mask. Rationale: The American Heart Association guidelines recom-
In what sequence, from first to last, should the nurse implement mend that the basic life support (BLS) algorithm should be initiated
these actions? (Place the first action on top and last action on the immediately in pediatric clients who are unresponsive or have a
bottom.) heart rate below 60 beats/minutes*** and exhibit signs of poor
perfusion. This child is manifesting poor perfusion as evidenced
1. Start chest compressions with assisted manual ventilations by a low blood pressure and poor oxygenation, so chest com-
2. Administer epinephrine 0.01 mg/kg intraosseous (IO) pression and assisted manual ventilation should be provided first,
3. Apply pads and prepare for transthoracic pacing followed by administration of drug therapy for persistent brady-
4. Review the possible underlying causes for bradycardia. cardia. Preparation with pad placement for transthoracic pacing
should be implemented next, followed by treatment indicated for
the underlying cause of the child's bradycardia.
An elderly male client is admitted to the mental health unit with
a sudden onset of global disorientation and is continuously con-
versing with his mother, who died 50 years ago.The nurse reviews
the multiple prescriptions he is currently taking and assesses Delirium
his urine specimen, which is cloudy, dark yellow, and has foul
odor. These findings suggest that his client is experiencing which Rationale: The client's clinical findings-polypharmia, urinary tract
condition? infection, and possible fluid imbalance are the most common
causes of cognition and memory impairment, which is character-
a. Delirium istic of delirium.
b. Depression
c. Dementia
d. Psychotic episode
Following an esophagogastroduodenoscopy (EGD) a male client
a. Prepare medication reversal agent
is drowsy and difficult to arouse, and his respiration are slow and
b. Check oxygen saturation level
shallow. Which action should the nurse implement? Select all that
, HESI RN COMPREHENSIVE EXIT EXAM VERSION VII- 160+ QUESTIONS AND ANSWERS
WITH RATIONALES|WELL STRUCTURED|A+ GRADED|
QUESTIONS ANSWERS
apply. c. Apply oxygen via nasal cannula
a. Prepare medication reversal agent Rationale: Sedation, given during the procedure may need to be
b. Check oxygen saturation level reverse if the client does not easily wake up. Oxygen saturation
c. Apply oxygen via nasal cannula level should be asses, and oxygen applied to support respiratory
d. Initiate bag- valve mask ventilation. effort and oxygenation. The client is still breathing so the bag-
e. Begin cardiopulmonary resuscitation valve mask ventilation and CPR are not necessary.
The nurse is planning preoperative teaching plan of a 12-years
old child who is scheduled for surgery. To help reduce the child
anxiety, which action is the best for the nurse to implement? Provide a family tour of the preoperative unit one week before the
surgery is scheduled
a. Give the child syringes or hospital mask to play it at home prior
to hospitalization. Rationale: School age children gain satisfaction from exploring
b. Include the child in pay therapy with children who are hospital- and manipulating their environment, thinking about objectives,
ized for similar surgery. situations and events, and making judgments based on what they
c. Provide a family tour of the preoperative unit one week before reason. A tour of the unit allows the child to see the hospital
the surgery is scheduled. environment and reinforce explanation and conceptual thinking.
d. Provide doll an equipment to re-enact feeling associated with
painful procedures
Assess IV site frequently for signs of extravasation
Which intervention should the nurse implement during the admin-
istration of vesicant chemotherapeutic agent via an IV site in the
client's arm? Rationale: Infiltration of a vesicant can cause severe tissue dam-
age and necrosis, so the IV site should be assessed regularly for
a. Explain the temporary burning of the IV site may occur. extravasation (B) of the chemotherapeutic agent.The client should
b. Assess IV site frequently for signs of extravasation be instructed to report any discomfort at the site (A). If pain and
c. Apply a topical anesthetic of the infusion site for burning burning occur, the IV should be stopped and C is not indicated.
d. Monitor capillary refill distal to the infusion site. Peripheral pulses, not D, provide the best assessment of perfusion
distal to the infusion should the drug extravasate or infiltrate.
When development a teaching plan for a client newly diagnosed
Give a dose of regular insulin per sliding scale
type 1 diabetes, the nurse should explain that an increase thirst is
an early sing of diabetes ketoacidosis (DKA), which action should
Rationale: As hyperglycemia persist, ketone body become a fuel
the nurse instruct the client to implement if this sign of DKA occur? source, and the client manifest early signs of DKA that include
excessive thirst, frequent urination, headache, nausea and vom-
a. Resume normal physical activity
iting. Which result in dehydration and loss of electrolyte. The client
b. Drink electrolyte fluid replacement
should determine fingerstick glucose level and self-administer a
c. Give a dose of regular insulin per sliding scale
dose of regular insulin per sliding scale.
d. Measure urinary output over 24 hours.
The nurse is teaching a group of clients with rheumatoid arthritis
about the need to modify daily activities. Which goal should the
nurse emphasize? a. Protect joint function
a. Protect joint function Rationale: Primary goal in the management of rheumatoid arthritis
b. Improve circulation is to protect and maintain joint function.
c. Control tremors
d. Increase weight bearing.
An adult client experiences a gasoline tank fire when riding a
motorcycle and is admitted to the emergency department (ED)
36%
with full thickness burns to all surfaces of both lower extremities.
What percentage of body surface area should the nurse document
Rational: according to the rule of nines, the anterior and posterior
in the electronic medical record (EMR)?
surfaces of one lower extremity is designated as 18 %of total body
surface area (TBSA), so both extremities equal 36% TBSA, other
36
options are incorrect.
(1 total leg front/back = 18, 1 total arm front/back = 9, torso = 18,
back = 18, head = 9, pubic = 1 = 100%)
A client with hyperthyroidism is receiving propranolol (Inderal). Decrease in pulse rate
Which finding indicates that the medication is having the desired
effect Rationale: Beta blockers such as propranolol help control the
symptoms of hyperthyroidism, such as palpitations or tachycardia,
a. Decrease in serum T4 levels but do not alter thyroid hormone levels, B is not a desired effect
