BSN 366 EXIT HESI Exam |Latest 2025/ 2026 Update | Questions and Answers |Verified Solutions |100% Guaranteed Pass |GRADED A

//BSN 366 EXIT HESI Exam |Latest 2025/ 2026 Update | Questions and Answers |Verified Solutions |100% Guaranteed Pass |GRADED A Question: A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has not been sleeping well lately and is experiencing labored breathing. List the client's problems in order of priority for the nurse. (Rank in the priority order from highest to lowest.) 1. Airway and breathing. 2. Pain management. 3. Definitive therapy. 4. Sleep and rest. Correct Answer: 1.Airway and breathing. 2.Pain management. 3.Sleep and rest. 4.Definitive therapy. Rationale First-level problems are immediate priorities (airway, breathing, and circulation). In this scenario, airway and breathing are the first priority, followed by pain management, Maslow's hierarchy of basic needs for rest and sleep, and then definitive drug therapies. Question: Which biological practices are federally regulated for healthcare workers? (Select all that apply.) Select all that apply 1.Standard precautions. 2. N-95 tuberculosis standard. 3. Blood-borne pathogen standard. 4. Biological product exposure limit (BPEL). 5. Resource Conservation and Recovery Act (RCRA). 6. As Low as Reasonably Allowable standard (ALARA). 3. Blood-borne pathogen standard. 5. Resource Conservation and Recovery Act (RCRA) Basic standards for healthcare workers, as delineated by Occupational Safety and Health Administration (OSHA), include standard precautions, droplet precautions using N-95 respiratory particulate masks when caring for a client who is positive for tuberculosis, and required annual updates for healthcare workers about blood-borne pathogen transmission, methods of minimizing exposure, and employee rights. Other options [BPEL and ALARA ] are not federally regulated. Question: A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I am never going to get well." What is the most therapeutic response? 1. "You need to stop thinking negative thoughts. They get in the way of your recovery." 2. "You are no bother to me or to the staff. We want you to get well and not feel sad anymore." 3. "I have known many clients with depression who have felt better after several weeks of treatment." 4. "You are feeling very pessimistic, but that is part of your illness. It should go away as you recover." 3. "I have known many clients with depression who have felt better after several weeks of treatment." Stating the observation that others have recovered can give a client hope. Telling a person to stop negtive thinking is ineffective because the client must be taught cognitive strategies to stop negative thinking. Stating the person is "no bother" is arguing with the client's beliefs and attempting to tell him how to feel, both of which are not therapeutic responses. Bring up pessimistic feelings interprets the client's feelings and does not provide the same degree of hope. Question: The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to inadequate primary defenses as evidenced by surgical incision and IV access." What nursing intervention should the nurse implement? 1. Limit visitors to immediate family to decrease exposure to infection. 2. Maintain "clean" technique in the change of wound dressing and IV site. 3. Assess and document skin condition around the incision and IV site at each shift. 4. Require the use of a face mask by staff when providing care requiring close contact. 3. Assess and document skin condition around the incision and IV site at each shift. Early identification of infection leads to prompt treatment and decreased nosocomial transmission to others, so the condition of any invasive lines or breaks in the skin should be assessed and documented during each shift. Question: A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir (J pouch). As part of preoperative teaching, what information should the nurse provide? 1. The transverse loop ostomy is permanent. 2. Easily removable appliances allow independence in self-care. 3. Daily irrigation is started after the J pouch heals. 4. Stool is eventually expelled through the rectum. 4. Stool is eventually expelled through the rectum. An ileal pouch-anal anastomosis (also known as the J pouch) is a surgically created ileoanal reservoir in the anal canal that preserves the rectal sphincter muscle, so that passage of stool through the rectum is the eventual result. To promote healing of the anastomosed parts of the colon, a temporary loop ostomy is created, not a permanent one. Although appliances that are easy to use are advantageous, the ostomy is reversed after healing takes place. Stool drains into the reservoir, so daily irrigation is not usually indicated. Question: The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a client who is breathing spontaneously. Which action should the nurse follow? 1. Check the pilot balloon to ensure that it is firm. 2. Verify the healthcare provider's prescription for the required cuff pressure. 3. Use a manometer to maintain cuff pressure between 25 and 30 mmHg. 4. Inject air until no air is auscultated over the larynx during a deep breath. 4. Inject air until no air is auscultated over the larynx during a deep breath. To achieve minimal pressure (minimal occlusion volume technique) against the tracheal wall, inject air into the tracheostomy tube cuff while auscultating with a stethoscope placed over the larynx (over the cuff) during inhalation. At the point when sounds of air movement cease, inflation is stopped, indicating that the cuff is sealed against the tracheal wall. Question: A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night sweats has a 10 mm induration after receiving a purified protein derivative (PPD) skin test. Which action should the nurse implement? 1. Refer for further diagnostic evaluation. 2. Determine exposure of others to the tuberculosis. 3. Begin anti-tubercular drug therapy. 4. Quarantine or isolate to control communicability. 1. Refer for further diagnostic evaluation. The PPD skin test results is indicative of exposure or latent Mycobacterium tuberculosis infection (LTBI), which this client is in a high-risk category for exposure in a homeless environment. Although productive prolonged cough, fever, and night sweats are common early symptoms, persons suspected of LTBI should not begin treatment until active TB disease has been excluded. Further diagnostic evaluation should be implemented. A dormant form that neither causes disease nor is communicable. Question: Which contextual factors are considered external environmental influences in the framework for occupational health programs and services? (Select all that apply.) Select all that apply 1. Economics. 2. Workforce. 3. Technology. 4. Interventions. 5. Socio-economic status. 6. Legislation/regulation. 1. Economics. 3. Technology. 6. Legislation/regulation. Economics affects the health of the company and its workforce productivity, in termsof profitability, growth, and expansion. Technology adds to an industry's capacity to develop and implement new or improved work processes. Legislation/regulation in the workplace, such as the blood-borne pathogen standard, affects the workforce in terms of requirements, administration, and control strategies. Occupational safety programs are built around the workforce to strive for maximum internal productivity. Interventions are internal environmental influences of an occupational health and safety program. Socio-economic status is a demographic variable commonly used in epidemiology. Question: The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates a disturbance in electrical conduction in the ventricles? 1. T wave of 0.16 second. 2. PR interval of 0.18 second. 3. QT interval of 0.34 second. 4. QRS interval of 0.14 second. 4. QRS interval of 0.14 second. The normal duration of the QRS is 0.04 to 0.12 second, so a prolonged QRS indicates an electrical anomaly in the ventricles. The T wave is normally 0.16 seconds. The PR interval range is 0.12 to 0.20 second. The QT interval should be 0.31 to 0.38 second. Question: The nurse is assigned a client with numerous treatments and decides it is not possible to complete all the needed treatments in the time scheduled for this shift. Which process should the nurse use? 1. Delegate tasks to competent team members. 2. Prioritize tasks with the most crucial needs first. 3. Report the incomplete treatments to next shift nurse. 4. Start with the easiest treatment first. 2. Prioritize tasks with the most crucial needs first. Planning care for a client with numerous treatments should be prioritized with the most crucial client needs first to the least. Delegating to others or reporting displace the nurse's responsibility to provide care. Starting with easiest is an inefficient utilization of time in meeting critical client needs. Question: A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? 1. Use disposable plates and utensils. 2. Stay in a room with the door closed. 3. Dispose of soiled dressings in plastic bags that are securely closed. 4. Others who are in the same room with the client should wear a mask. 3. Dispose of soiled dressings in plastic bags that are securely closed. Contact precautions require the use of a barrier that prevents contact with wound secretions on soiled dressings, which are best disposed of in tightly closed plastic bags. Disposable dishes is not necessary with contact precautions. Isolating themself to one room or wearing masks should be implemented for airborne, droplet precautions, or protective environments. Question: When assessing a client's interior eye structures with an ophthalmoscope, which action should the nurse use? 1. Use a red-free filter. 2. Adjust the diopters. 3. Direct a wide-beam light. 4. Dilate the client's pupils. 2. Adjust the diopters. The diopter corresponds to the magnification power of the ophthalmoscope's lens, which is adjusted to bring the retina into focus when a client's error of refraction, such as myopia or hyperopia, causes a change in the eyeball shape. Using a red-free filter produces a green beam for examination of the optic disc for pallor and recognition of retinal hemorrhages. The direct wide-beam light is used to examine the anterior eye. The application of an ophthalmic mydriatic should be instilled prior to extended fundoscopic visualization. Question: The nurse administers dopamine (Intropin) IV infusion at 3 mcg/kg/min to a critically ill, hypotensive client. What is the intended effect of this treatment? To increase 1. blood pressure to 140/80. 2. urine output to 55 ml/hr. 3. pulse to 132 beats/min. 4. respirations to 24 breaths/min. 2. urine output to 55 ml/hr. The expected outcome of this treatment is an increase in urine output due to increased renal perfusion. Dopamine, a catecholamine, provides renal and mesenteric vasodilation at a low dosage level, such as the 3 mcg/kg/minute infusion that was prescribed for this client. A higher dose of dopamine is indicated in a critically ill client who is hypotensive. Question: During an admission assessment interview, a client states, "I do not use many drugs." How should the nurse respond? 1. "Tell me about the drugs you use now." 2. "Explain what you mean by many drugs." 3. "Do you mean legal drugs or illegal ones?" 4. "What kind of drugs are you talking about?" 1. "Tell me about the drugs you use now." Open-ended questioning allows the client provide specific information without probing. Asking the person to explain what drugs they are taking is critical of the client's descriptors and does not encourage further dialog. Asking about legal vs. illegal drugs or "kind of drugs" both are close-ended questions that require one word responses, and stop further exploration with the client. Question: The nurse begins a physical assessment of an 8-month-old. The child is sitting contentedly on the mother's lap, chewing on a toy. Which action should the nurse implement first? 1. Elicit reflexes. 2. Auscultate heart and lungs. 3. Examine eyes, ears, and mouth. 4. Take an axillary temperature. 2. Auscultate heart and lungs. The sequence for physical examination in a quiet child begins with auscultation of heart and lungs to enable the nurse to hear the breath and heart sounds clearly. Question: Which client is at highest risk for chronic kidney disease (CKD) secondary to diabetes mellitus (DM)? 1. Type 1 DM and a serum hemoglobin-A1c of 3.5%. 2. Type 1 DM and retinopathy and mild vision loss. 3. Type 2 DM and hypertension controlled by metoprolol. 4. Type 2 DM and a history of morbid obesity for 5 years. 2. Type 1 DM and retinopathy and mild vision loss. Diabetic retinopathy and nephropathy are related to prolonged hyperglycemia and hypertension which damage the microvasculature of the eyes and kidneys, so a client with Type 1 DM and retinopathy is most likely to develop nephropathy and CKD. The client with hemoglobin A1C of 3.5% is demonstrating compliance with therapy (H-A1c target level is no greater than 7%), which indicates tight glucose control and reduces the risk for microvascular complications. The client with controlled hypertension is less likely to develop CKD, although metoprolol, a beta adrenergic receptor antagonist, can mask the signs of hypoglycemia. A client with Type 2 DM is more likely at risk for complications associated with chronic obesity. Question: A client with acute pancreatitis is admitted to the medical unit. During the nurse's admission interview, which assessment has the highest priority? 1. History of alcohol intake. 2. Time of last meal. 3. Frequency of vomiting. 4. Intensity of pain. 4. Intensity of pain. The hallmark sign of pancreatitis is severe abdominal pain due to autodigestion of the pancreas by the enzymes amylase and lipase. Question: A client who is 12 hours post total thyroidectomy develops stridor on exhalation. What is the nurse's first action? 1. Hyperextend the client's neck. 2. Call for emergency assistance. 3. Document the finding as a normal expectation. 4. Reassure the client that the voice change is temporary. 2. Call for emergency assistance. Stridor upon exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema postoperatively. In life-threatening complications, such as respiratory obstruction or bleeding, a call for emergency assistance should be made first in the event intubation is required. Extending the clients neck is contraindicated. Although documentation is necessary, a stridor or voice change are indicators of early airway compromise. Question: A woman visits the clinic for confirmation of pregnancy. All of her children from prior pregnancies are living. One was born at 39-weeks gestation, twins at 34-weeks gestation, and another singleton at 35weeks gestation. How should the nurse record her gravity and parity using the GTPAL system? A. 3-0-3-0-3. B. 3-1-1-1-3. C. 4-1-2-0-4. D. 4-2-1-0-3. C. 4-1-2-0-4. Using the GPTAL system is the correct record of gravity and parity. G reflects the total number of times the woman has been pregnant; she is pregnant for the 4th time. T indicates the number of pregnancies carried to term, not the number of deliveries at term; she has had only one pregnancy after 37-weeks gestation. P is the number of pregnancies that resulted in a preterm birth, not the number of infants born; she has had two pregnancies before 37-weeks gestation. A signifies elected abortions or miscarriages prior to the period of viability (20-weeks). L signifies the number of children born that are currently living. Question: The registered nurse (RN) and practical nurse (PN) are working together to care for a group of clients. Which situation requires intervention by the RN? 1. A client receiving Lactated Ringer's solution requests pain medication. 2. A client with a history of falls needs assistance to the bathroom. 3. A client's indwelling urinary catheter requires manual irrigation. 4. A client with an epidural infusion reports lower extremity parasthesia. 4. A client with an epidural infusion reports lower extremity parasthesia. Assessment of possible adverse effects of an epidural infusion should be performed by the RN, who has the expertise to evaluate the significance of the assessment data. The other options are skills that can be delegated to the PN. Question: The charge nurse working on a surgical unit must discharge as many clients as possible to prepare for emergency admissions. Which client is stable enough to be discharged from the unit? 1. An older client with end-stage cirrhosis who had a liver biopsy 4 hours ago. 2. A client scheduled for a femoro-popliteal bypass surgery tomorrow. 3. A middle-aged client with acute pancreatitis and lower left quadrant pain. 4. A female client with angina and ectopy noted on the telemetry monitor. 2. A client scheduled for a femoro-popliteal bypass surgery tomorrow. The client with an elective surgical procedure can be rescheduled for a later date so is considered stable enough to be discharged. A client with a recent biopsy is not stable for discharge as the procedure can result in bleeding due to the high vascularity of the liver. A client with acute pancreatitis is unstable, in acute pain, and at risk for rupture of diverticula. A client with rhythm irregularities has a life-threatening condition because of the risk for ventricular tachycardia. Question: The cardiac monitor of a 50-year-old client admitted for cocaine ingestion shows ventricular tachycardia (VT) converting to ventricular fibrillation (VF). What priority action should the nurse implement? 1. Prepare for intubation. 2. Defibrillate at 200 joules. 3. Insert intravenous catheter. 4. Obtain arterial blood gases. 2. Defibrillate at 200 joules. After confirming ventricular fibrillation, rapid defibrillation is critical in re-establishing cardiac output and preserving vital organ function. After CPR is initiated and defibrillation attempted, airway intubation and intravenous access are indicated for successful resuscitation. Arterial blood gases are obtained during or after resuscitation to determine medical management for metabolic acidosis which occurs secondary to anaerobic glycolysis during VF or cardiac arrest. Question: What is the most effective way to implement a teaching plan? 1. Teach the information that the client wants to learn first. 2. Streamline the teaching plan to include only essential information. 3. Present to the client all the information necessary to meet the objectives. 4. Provide the client with written material to review before teaching sessions. 1. Teach the information that the client wants to learn first. Teaching is most effective when it responds to the learner's needs, and learning begins when a person identifies a need for knowing or acquiring an ability to do something. Question: The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? 1. Use an electronic sphygmomanometer to take the BP every 30 minutes. 2. Retake the blood pressure in the same arm, deflating the cuff slowly. 3. Ask another nurse to recheck the blood pressure to compare results. 4. Obtain another blood pressure cuff and retake the blood pressure. 2. Retake the blood pressure in the same arm, deflating the cuff slowly. The nurse should first retake the blood pressure in the right arm, deflating the cuff more slowly because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. There is no indication that the BP needs to be taken frequently. If the blood pressure remains low, further assessment is needed, which may include asking other staff to recheck the BP. If deflating the cuff slowly does not resolve the discrepancy, the nurse may then need to implement getting another BP cuff and retaking the BP. Question: A male client on a psychiatric unit becomes extremely agitated and begins to smash his head against doors. He seems frightened, and his verbalizations suggest he is experiencing distorted sensory perceptions. What action should the nurse take first? 1. Place the client in mechanical restraints until calm. 2. Administer a PRN dose of haloperidol (Haldol) IM. 3. Use a calm, soothing voice to diffuse the situation. 4. Encourage the client to focus on his feelings of anger. 1. Place the client in mechanical restraints until calm This client is demonstrating behaviors that may be a danger to himself or others, and in such an emergency situation, restraints may be applied by an authorized staff member. This client is experiencing distorted sensory perceptions, so he is unlikely to respond to or have the ability to verbalize his feelings. Question: Designated funds are received to address the healthcare needs of a community's vulnerable populations. Which group qualifies for this funding? 1. African-American women who are 30 to 35 years of age. 2. Survivors of violence that occurred at least 5 years ago. 3. Active armed forces reserve unit returning from Europe. 4. Full-time students who are attending public colleges. 2. Survivors of violence that occurred at least 5 years ago Vulnerable populations are those groups who have an increased risk of developing adverse health outcomes. Survivors of violence, even though the violence occurred more than 5 years ago, have an increased risk for adverse health outcomes. The other options just describe demographic groups. Question: A child weighing 44 pounds is receiving a bolus of Ringer's Lactate solution for fluid replacement at 20 ml/kg. How many ml should the nurse administer? (Enter numeric value only.) 400 mL Isotonic crystalloid solution (normal saline or lactated Ringer's solution) is usually the first choice for fluid replacement in children and is given in IV boluses of 10 to 20 ml/kg over 10 to 15 minutes and repeated as necessary. First convert the pounds to kg, then multiply by 20 ml. 44 pounds 2.2 pounds/kg = 20 kg 20 ml = 400 ml. Question: When assessing an intravenous (IV) solution infusing by gravity, the nurse observes that the IV fluid continues to flow when pressure is applied above the catheter tip. What action should the nurse implement? 1. Lower the extremity below the level of the client's heart. 2. Gather the supplies needed to discontinue the IV fluid. 3. Obtain an intravenous infusion pump to regulate the rate of infusion. 4. Convert the IV to a saline lock until the healthcare provider is notified. 2. Gather the supplies needed to discontinue the IV fluid. An IV infusion stops when pressure is placed on the skin above the tip of the catheter, but will continue to flow into the subcutaneous tissue if there is infiltration, which requires removal of the IV. The other options will not resolve the infiltration. Question: Which outcome statement or goal should the nurse include in the plan of care of an adolescent diagnosed with anorexia nervosa? 1. Improve the client's body perception. 2. Consume at least 50% of all meals. 3. Exercise no more than one hour daily. 4. 5% decrease in serum potassium levels. 2. Consume at least 50% of all meals. An outcome statement should be measurable and provide observable behaviors that indicate the client's problem is resolving. Self-starvation is the major problem associated with anorexia nervosa, so stating the person should consuming 50% of diet should be included in this client's plan of care. "Improve body perception" is vague and not measurable. Adolescents with anorexia nervosa often obsessively exercise to lose additional weight, so defining exercise time limits may be excessive. Clients with anorexia have an increased risk for hypokalemia, so decreasing serum potassium levels is an inappropriate goal for this client. Question: The nurse working in the oncology clinic at a cancer center is involved in supporting clients and families who must cope with the diagnosis of cancer. Which client is likely to cope best with the diagnosis of cancer? 1. An older man who is always happy and chooses to view only the good in every situation. 2. A single mother who seeks the support of her two teenage daughters during difficult times. 3. A successful businessman who is accustomed to handling highly-stressful situations. 4. A teacher who seeks information about her disease and wants to continue teaching. 4. A teacher who seeks information about her disease and wants to continue teaching. Those who seek information about their disease while attempting to carry on with their lives as best they can are likely to handle the diagnosis of cancer best. Those who use repression to deal with traumatic events often have difficulty expressing their feelings. Depending on children for support, especially when the children are teenagers, may be disappointing. Someone who is used to handling high-stress situations is used to being in control, and control over a life-threatening diagnosis is not always possible. Question: A client with severe preeclampsia is receiving magnesium sulfate 2 grams IV hourly. The nurse assesses the client and finds: blood pressure 140/90, pulse 100, respirations 10, deep tendon reflexes 1+, and urinary output 130 ml in 4 hours. The nurse will discontinue the magnesium infusion based on which assessment finding? 1. Deep tendon reflexes 1+. 2. Blood pressure of 140/90. 3. Respirations of 10. 4. Urinary output of 130 ml in 4 hours. 3. Respirations of 10. With respirations less than 12, the client is at risk for developing respiratory arrest and the magnesium sulfate should be discontinued. Other cardinal signs of magnesium toxicity include urinary output <100 ml/4 hours (or 25 ml/hour) (D) and absent reflexes. Reflexes of 1+ are hypoactive but present. A client with preeclampsia can seize with blood pressures lower than 140/90. Magnesium sulfate is not an antihypertensive. Question: A male client is receiving total parenteral nutrition (TPN) through a central venous catheter (CVC) in the right subclavian vein and is reluctant to move his right arm or turn his head toward the CVC site. What nursing action should the nurse implement first? 1. Flush the catheter to maintain patency of the CVC access. 2. Describe the placement and rationale for care of the catheter. 3. Reassure the client that the TPN administration is temporary. 4. Provide passive range of motion to the right arm and neck. 2. Describe the placement and rationale for care of the catheter. A client's anxiety or fear about a treatment or procedure is commonly the result of a lack of knowledge, so providing information, such as drawings or pictures, and explanations about the catheter, may help the client understand the catheter's function and decrease his anxiety regarding its presence. Question: Following the administration of morphine sulfate 10 mg IV, the nurse determines that the client's respirations are six breaths per minute. What action should the nurse take first? 1. Assess the client's current oxygen saturation level. 2. Auscultate the client's breath sounds bilaterally. 3. Prepare to administer a dose of naloxone (Narcan) IV. 4. Attempt to arouse the client to stimulate respirations. 4. Attempt to arouse the client to stimulate respirations. The nurse should first attempt to stimulate respirations by arousing the client. This measure is noninvasive and may produce an immediate increase in respiratory rate. If this action is unsuccessful, the nurse should then implement the other options listed. Question: A client with aortic valve stenosis develops heart failure (HF). Which pathophysiological finding occurs in the myocardial cells as a result of the increased cardiac workload? 1. Increase in size. 2. Decrease in length. 3. Increase in number. 4. Decrease in excitability. 1. Increase in size. Hypertension and incompetent or stenotic heart valves cause an increase in the workload of the heart by increasing afterload which requires an increase in the force of contraction to pump blood out of the heart. Myocardial hypertrophy results because the cells increase in surface area or size by increasing the amount of contractile proteins, but the quantity of fibers remain constant. As myocardial hypertrophy progresses, the heart becomes ineffective as a pump because the ventricular wall cannot develop enough tension to cause effective contraction, which causes myocardial irritability due to hypoxia. Question: A client is receiving a continuous IV infusion and intermittent IV antibiotics. The nurse should plan to collaborate with the case manager regarding which aspect of this client's care? 1. Determination of the compatibility of the intravenous fluids and prescribed antibiotics. 2. Provision of nursing staff education about safe administration of IV antibiotics. 3. Maintenance of data related to the number of IV infiltration occurrences in the hospital. 4. Evaluation of the need for continued IV antibiotics to achieve the desired outcomes. 4. Evaluation of the need for continued IV antibiotics to achieve the desired outcomes. The nurse may collaborate with the case manager to evaluate the need for continued IV antibiotics. The role of the case manager is to ensure desired client outcomes in a cost-effective manner. Looking at compatibilities is within the nurse's scope of practice. Staff education about IV antibiotics is a role of the nurse, or a nurse-educator. Data related to IV infiltration is a role of the quality improvement team. Question: A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement? 1. Encourage the student to associate with non-smokers only while attempting to stop smoking. 2. Tell the student that he is still young and should continue to try various smoking cessation methods. 3. Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness. 4. Provide the student with the latest research data describing the long-term effects of tobacco use. 1. Encourage the student to associate with non-smokers only while attempting to stop smoking. It is difficult to cease smoking when surrounded by those who smoke, and adolescents are particularly influenced by peers. Question: A new mother asks the nurse why her infant son has yellow liquid coming out of his eyes. Which explanation is correct? 1. "An antibiotic ointment is placed in each newborn's eyes to prevent infection." 2. "Conjunctivitis neonatorum is common in newborns." 3. "This type of question should be discussed with your pediatrician." 4. "Most infants have drainage from their eyes which usually resolves within 2 to 3 days of life." 1. "An antibiotic ointment is placed in each newborn's eyes to prevent infection." Antibiotic ointments, such as erythromycin ointment, are placed in the lower conjunctiva of each eye to prevent chlamydia and gonorrhea. Question: The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan? 1. Hand washing prior to preparation of the injection. 2. Method used to aspirate medication from a vial. 3. Selection and rotation of injection sites. 4. Proper disposal of injection equipment. 2. Method used to aspirate medication from a vial. To maintain sterility of the procedure, the most important factor to include in the teaching plan is how to manipulate the syringe parts so that the medication maintains sterility during the preparation and administration. The other options are teaching topics, but are not components of maintaining sterile technique while administering an injection. Question: What is the underlying pathophysiologic process between free radicals and destruction of a cell membrane? 1. Inadequate mitochondrial ATP. 2. Enzyme release from lysosomes. 3. Defective chromosomes for protein. 4. Defective integral membrane proteins. 2. Enzyme release from lysosomes. Oxidative damage to cells is thought to be a causative factor in disease and aging. If free radicals bind to polyunsaturated fatty acids found in the lysosome membrane, the lysosome, nicknamed "suicide bags", leaks its protein catalytic enzymes intracellularly and the cell is destroyed.Inadequate ATP production and defective protein synthesis lead to cell death either as the result of defective chromosomes or production of defective integral proteins. Question: The nurse is preparing to perform oral care for an unconscious client.In what order should the nurse implement the nursing actions? (Arrange the options in the order they should be performed with the first action on top and the last action on the bottom.) 1. Raise bed to a comfortable working height. 2. Position the client in a flat side-lying position. 3. Place an emesis basin under the client's chin. 4. Lower the side rail between the nurse and the client. 1. Raise bed to a comfortable working height. 2. Lower the side rail between the nurse and the client. 3. Position the client in a flat side-lying position. 4. Place an emesis basin under the client's chin. To ensure client and nurse safety when performing oral care for an unconscious client, first raise the bed to a comfortable working level, then lower the side rail between the nurse and the client, position the client in a flat side-lying position, and place a towel and an emesis basin under the client's chin. Question: An overweight adolescent girl has been to the school nurse three times in the last two months complaining of vaginal and urinary tract infections. What action should the nurse take first? 1. Counsel the girl regarding hygiene. 2. Ask if she is going to the bathroom frequently. 3. Teach the girl the importance of practicing safe sex. 4. Encourage the girl to see the school counselor. 2. Ask if she is going to the bathroom frequently. The nurse should ask questions directed toward symptoms of diabetes. Recurrent vaginal and urinary tract infections are often an early sign of diabetes. Question: A client who had a cesarean section two weeks ago is admitted to the hospital for an infected surgical abdominal wound. Which room is best for the nurse to assign this client? 1. A negative pressure room. 2. A semi-private room on a surgical unit. 3. A postpartum room in the birthing center. 4. A private room on a medical unit. 4. A private room on a medical unit. To protect others from contamination, the nurse should assign this client to a private room. Isolation room is not indicated(A) is an isolation room used for clients with TB. (B) should not be assigned because of the possibility of cross-contamination by the infected client. (C) should not be assigned because the OB unit is considered "clean." Question: A client with glaucoma is scheduled for surgery. Which pre-operative prescription should the nurse question? 1. Morphine sulfate 5 mg IV on call to operating room. 2. Atropine sulfate 0.4 mg IM on call to operating room. 3. Betaxolol (Betoptic) one drop in each eye the morning of surgery. 4. Benzodiazepine (Valium) 5 mg by mouth the morning of surgery. 2. Atropine sulfate 0.4 mg IM on call to operating room. Many ophthalmic agents used to reduce intraocular pressure (IOP) in glaucoma cause miosis, which increases the outflow of aqueous humor. Atropine is an anticholinergic agent that causes mydriasis, which can increase IOP and counteracts the action of β-blocking agents, so Atropine prescription should be brought to the attention of the healthcare provider. Question: What assessment findings should the nurse identify before referring a client for further evaluation to rule out skin cancer? (Select all that apply.) Select all that apply Some correct answers were not selected 1. White patches. 2. Cherry angiomas. 3. Border irregularity. 4. Lesion with asymmetry. 5. Lesion with color variations. 6. Lesion of 3 to 5 mm diameter. 3. Border irregularity. 5. Lesion with color variations. ABCDE is the acronym used by the American Cancer Society (ACS) to monitor lesions needing further evaluation to rule out skin cancer: A for asymmetry of the lesion; B for irregular border; C for color, usually dark; D for diameter equal to or greater than 6 mm; and E for elevation. A lesion with any of the characteristics of ABCDE should be evaluated by a healthcare provider. Lesions that lack the color variable, are raised, dome-shaped, or benign clusters of blood vessels that do not require treatment. Lesions of 3 to 5 mm diameter are small and may be monitored instead of treated. Question: A client is receiving a continuous bladder irrigation at 1000 ml/hour after a prostatectomy. The nurse determines the client's urine output for the past hour is 200 ml. What action should the nurse implement first? 1. Notify the healthcare provider. 2. Stop the irrigation flow. 3. Document the finding and continue to observe. 4. Irrigate the catheter with a large piston syringe. 2. Stop the irrigation flow. The urinary output should be at least the volume of irrigation input plus the client's actual urine. A significant decrease in output indicates obstruction in the drainage system, and the irrigation flow should be stopped to prevent severe bladder distention. The next action is to check the external system for kinks or obstruction. If no output occurs, the catheter is irrigated with 30 to 50 ml of normal saline using a large piston syringe. If the obstruction is not resolved, then the healthcare provider should be implemented. Question: After receiving chemotherapy 2 weeks ago, a male client with acute leukemia is admitted for blood transfusions because his hemoglobin is 6 gm/dl. After toileting, the client returns to bed and his oxygen saturation is measured at 82%. The nurse increases the O2 per nasal cannula from 3 to 4 liters per minute. What intervention should the nurse implement next? 1. Collect blood for hemoglobin and hematocrit. 2. Start the first transfusion of blood. 3. Insert an indwelling urinary catheter. 4. Encourage alternate rest periods with activity. 2. Start the first transfusion of blood. The hemoglobin of 6 gm/dl (normal is 14 to 18 gm/dl in males) and the 82% O2 saturation (normal is 96 to 100%) indicates the client is hypoxic, so the first transfusion of blood should be started. Rechecking labs should be obtained after the client is transfused to evaluate its effectiveness. Placing a catheter is not indicated at this time. Rest periods should be included in the plan of care, but is not as essential as giving the transfusion at this time. Question: The nurse observes an empty secondary infusion of diltiazem (Cardizem) is attached to the client's IV pump, but realizes that this client has no prescription for Cardizem. In what sequence, from first to last, should the following interventions be implemented? (Place the first action on top and last action on the bottom.) 1. Measure the client's vital signs. 2. Review medications client is taking. 3. Complete an incident report. 4. Notify the healthcare provider. 1. Measure the client's vital signs. 2. Review medications client is taking. 3. Notify the healthcare provider. 4. Complete an incident report. Cardizem is a calcium channel blocker that decreases blood pressure, and slows SA or AV node conduction, which can cause bradycardia or cardiac arrhythmias, so the client's vital signs should be measured first to determine the client's reaction to the medication error. The client's current medications should be reviewed before notifying the healthcare provider, and then the incident report completed. Question: About mid-morning, a 10-year-old child reports to the school nurse complaining of nausea, dizziness, and chills. Further assessment reveals that this child is sweating profusely and has a blood glucose level of 57 mg/dl. Based on these assessment findings, which food is best for the nurse to encourage the child to eat? 1. A chocolate bar. 2. A soft drink. 3. Peanut butter crackers. 4. A piece of buble gum. 3. Peanut butter crackers. Peanut butter crackers provide a complex carbohydrate, plus protein and fat. This child is exhibiting signs and symptoms of mild to moderate hypoglycemia and needs to eat about 15 grams of carbohydrates to increase the blood sugar level. Complex carbohydrates are broken down more slowly and are slower acting than simple sugars, so they prevent the blood glucose level from peaking and then dropping precipitously. Question: A client with a markedly distended bladder is diagnosed with hydronephrosis and left hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650 ml. This finding supports which pathophysiological cause of the client's urinary tract obstruction? 1. Obstruction at the urinary bladder neck. 2. Ureteral calculi obstruction. 3. Ureteropelvic junction stricture. 4. Partial post-renal obstruction due to ureteral stricture. 1. Obstruction at the urinary bladder neck. Hydroureter (dilation of the renal pelvis), vesicoureteral reflux (backward movement of urine from the lower to upper urinary tracts), and hydronephrosis (dilation or enlargement of the renal pelvis and calyces) result from post-renal obstruction which can consequently result in chronic pyelonephritis and renal atrophy. Ascending urinary reflux occurs when normal ureteral peristaltic pressure is met with an increase in urinary pressure occurring during bladder filling if the urinary bladder neck is obstructed. Question: When making a home visit to a family with a teething 4-month-old, what information is most important for the nurse to provide the parents? 1. Though child development is characterized by individual differences, first teeth usually erupt during the seventh month. 2. Providing cooled teething toys can help decrease the discomfort associated with tooth eruption. 3. No action is required for the common symptoms associated with teething, which include drooling, irritability, and poor sleeping. 4. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention. 4. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention. A slight fever that persists longer than three days is likely to be associated with a pathological process, not teething, and the parents should seek the attention of their healthcare provider if it occurs. Question: A client who had a normal vaginal delivery 10 days ago is re-hospitalized for lethargy and increased lochia flow with a foul odor. Initial assessment reveals a pulse rate of 94 beats/minute, a temperature of 102.2 F, chills, pelvic pain, and uterine tenderness. What action should the nurse take? 1. Review the complete blood count. 2. Tell client to discard pumped milk. 3. Initiate a 24-hour urine collection. 4. Arrange for the baby to room-in. 1. Review the complete blood count. This client is exhibiting symptoms of endometritis, and an elevated white blood count suggests infection. The breast milk is not contaminated, so a breast pump should be provided to maintain lactation. Collection of a 24-hour urine specimen is not indicated for a client with endometritis. Infant safety is jeopardized by a client exhibiting these symptoms, so rooming-in should be discouraged. Question: A nurse is caring for a male client with paranoid schizophrenia who believes that his antipsychotic medications are poison. Which intervention is best for the nurse to implement? 1. Describe the need for consistently taking medications. 2. Offer the medication in a concentrated form. 3. Discard the medication and document the client's refusal. 4. Approach the client with the medication 30 minutes later. 4. Approach the client with the medication 30 minutes later. Delusions of persecution and fear of being controlled by others are characteristic of those with paranoid schizophrenia, but these feelings fluctuate, and in 30 minutes the client may be willing to take the medications. Question: A male client who is two days postoperative for a bowel resection moves as little as possible and does not use the incentive spirometer unless specifically reminded. The client reports his pain level at an 8 on a 10-point scale, but refuses a PRN dose of an opioid analgesic and tells the nurse that he can "tough it out." What response is best for the nurse to provide? 1. Side effects are not a concern because they usually decrease over time. 2. Very few clients become addicted to opioids when using them for pain control. 3. There are multiple options of medications that can be offered if one drug does not relieve the pain. 4. Unrelieved pain impairs respiratory and gastrointestinal function and can impair recovery from surgery. 4. Unrelieved pain impairs respiratory and gastrointestinal function and can impair recovery from surgery. Unrelieved pain can result in increased morbidity as a result of respiratory dysfunction, increased heart rate, cardiac workload, increased muscular contraction and spasm, decreased gastrointestinal motility and transit, and increased catabolism. Question: Parents of a toddler tell the nurse that their child eats little at mealtime, sits at the table with the family only briefly, and wants snacks "all the time." What recommendation should the nurse provide? 1. Give the toddler nutritious snacks. 2. Offer rewards for eating at mealtimes. 3. Avoid snacks so the child is hungry at mealtimes. 4. Explain to the child in a firm manner what is expected. 1. Give the toddler nutritious snacks. At approximately 18 months of age, most toddlers manifest lower nutritional need and decreased appetite, a phenomenon known as "physiologic anorexia" which is often manifested as a picky, fussy eater with strong taste preferences, and erratic eating patterns. Toddlers are learning to differentiate self and social boundaries and may be disruptive while sitting at the table, so offering nutritious finger foods is a good way to ensure proper nutrition during this stage. Question: Which intervention should the school nurse implement to decrease the incidence of hepatitis A in a preschool setting? 1. Promote hygiene by ensuring that children's faces and hair are kept clean. 2. Ensure that all enrolled children have been immunized for Hepatitis A. 3. Put a strip bandage on bleeding injuries to prevent contamination of others. 4. Teach children the correct handwashing technique to use after toileting. 2. Ensure that all enrolled children have been immunized for Hepatitis A. The CDC recommended immunization schedule for children includes the hepatitis A vaccine (HAV), so follow-up of enrolled children's immunization status with HAV or human-immune gamma globulin should be implemented. Preschoolers should be taught the importance of hygiene practices, such as keeping themselves clean or correct handwashing technique, but hepatitis A is transmitted via the fecaloral route and immunization provides the best universal protection. Hepatitis A is not transmitted through blood contact. Question: The unlicensed assistive personnel (UAP) informs the nurse that a client whose heart rhythm has been stable is now exhibiting a rapid, irregular pulse. What action should the nurse implement first? 1. Document the change in pulse rate on the graphics sheet. 2. Review the client's medical history for cardiac problems. 3. Reassess the rate and characteristics of the client's pulse. 4. Ask the UAP to recheck the client's pulse in thirty minutes. 3. Reassess the rate and characteristics of the client's pulse. A change in heart rate or rhythm reflects a change in physiologic homeostasis that may be potentially life threatening, so it is most important to immediately reassess the client's pulse rate and characteristics. After reassessing the client, the nurse should document the findings, review the client's medical record for related history, and determine further needed intervention, such as rechecking the client's vital signs. Question: The blood pressure readings obtained by a unlicensed assistive personnel (UAP) are consistently different from those obtained by other staff members. What action should the charge nurse take first? 1. Counsel the UAP about the inaccurate blood pressure readings. 2. Observe the UAP performing blood pressure measurements. 3. Make staff members aware of the possible errors in blood pressure readings. 4. Ask the education department to provide additional training for the UAP. 2. Observe the UAP performing blood pressure measurements. The charge nurse should first observe the UAP's performance to determine if the UAP is performing the task appropriately. If the UAP needs education, the charge nurse can provide instruction real time. Question: Which assessment is most important for the nurse to implement when performing a comprehensive assessment for an older adult? 1. Chronic illnesses. 2. Functional abilities. 3. Immunologic function. 4. Physical signs of aging. 2. Functional abilities. The focus of a geriatric assessment is to determine the older client's functional abilities, so appropriate interventions can be planned and implemented to maintain and enhance independence. Question: When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next? 1. Place a sterile drape under the client's buttocks. 2. Instruct the client to inhale and then exhale slowly. 3. Discard the gloves and apply new sterile gloves. 4. Apply a sterile lubricant to the end of the catheter. 4. Apply a sterile lubricant to the end of the catheter. After testing the balloon for patency, the nurse should next lubricate the end of the catheter. The sterile drape should already be positioned under the client's buttocks. The client is instructed in breathing just prior to insertion. Question: A client is receiving an intramuscular injection at the ventrogluteal site. At what angle should the nurse insert the needle? (Enter numeric value only.) 90 The angle for needle insertion when performing intramuscular injections is 90 degrees. Question: The nurse asks an older female client with cognitive impairment who has been hospitalized for three days how her previous evening was. The client replies, "I had the best time. My husband took me out to dinner and then to a concert. The music was wonderful." Which term should the nurse document to best describe the client's response? 1. Delusions. 2. Confabulation. 3. Concretization. 4. Circumstantiality. 2. Confabulation. Confabulation describes the client's story that is made-up to fill in the gaps of memory when one is unable to remember something that might have happened. Question: A client has a precipitous delivery attended only by the nurse. What nursing intervention has the highest priority? 1. Ensure an adequate airway in the newborn. 2. Massage the uterine fundus until it is firm. 3. Clamp and cut the umbilical cord. 4. Assess for signs of placental detachment. 1. Ensure an adequate airway in the newborn. Ensuring an adequate airway in the newborn is the first intervention that should be implemented. Suctioning of secretions should be performed immediately. Airway of newborn is priority. Question: Which action should the nurse take first when performing tracheostomy care? 1. Cleanse around the stoma. 2. Suction the tracheostomy. 3. Oxygenate with 100% oxygen. 4. Secure the new neck strap. 3. Oxygenate with 100% oxygen. Hyperinflation with 100% oxygen helps minimize hypoxia and atelectasis during the suctioning procedure, so the nurse should take this action first, before any of the other options. Question: A client at 13-weeks gestation is scheduled for an amniocentesis in one week. The nurse knows that the primary reason for conducting this procedure is to obtain what information? 1. Level of fetal lung maturity. 2. Presence of genetic disorders. 3. Quantification of alpha-fetoprotein levels. 4. Determination of gestational age. 2. Presence of genetic disorders. Amniocentesis is done at 14 to 16 weeks gestation to determine chromosomal, genetic, and metabolic disorders. Amniocentesis in the third trimester assesses fetal lung maturity by evaluating the lecithin/sphingomyelin (L/S) ratio and the presence of phosphatidylglycerol (PG). Amniocentesis is performed to quantify alpha-fetoprotein levels after abnormal maternal serum alpha-fetoprotein levels (done at 15 to 18 weeks ) are found. Question: The nurse is caring for a client with ulcerative colitis and formulates a nursing diagnosis of, "Impaired skin integrity related to diarrhea." What client behavior demonstrates that the teaching regarding perianal care is effective? 1. Soaks in a sitz bath for 40 minutes after each diarrhea stool. 2. Takes prescribed antidiarrheal medication after each diarrhea stool. 3. Applies witch hazel compresses to provide relief from anal irritation. 4. Cleans perianal area with mild soap and water after each diarrhea stool. 4. Cleans perianal area with mild soap and water after each diarrhea stool. To remove bacteria, provide comfort, stimulate circulation, and prevent skin breakdown, the client is demonstrating effective perianal care when the perianal area is cleansed after each bowel movement with mild soap and warm water, and then dried thoroughly Question: The nurse is providing discharge teaching about crutch walking to a young adult with a fractured foot who has a prescription for partial weight-bearing. Which intervention should the nurse to implement before the client is discharged? 1. Review the client's most recent serum calcium level. 2. Verify that the crutches fit snugly under the axilla. 3. Observe the client while demonstrating crutch walking. 4. Determine if the client lives alone or with others. 3. Observe the client while demonstrating crutch walking. To evaluate a client's ability to crutch walk, the nurse should observe the client perform the skill. It is not necessary to check the client's serum calcium level. Crutches should be two to three inches from the axilla to prevent brachial plexus damage. Living alone should not be a problem because the client can use the three point gait with the crutches to perform self-care. Question: Which responsibility best describes the role of a nurse as manager? 1. Development of long range career goals. 2. Maintenance of harmony within the agency. 3. Assignment of nursing personnel and resources. 4. Delivery of client care while meeting agency goals. 4. Delivery of client care while meeting agency goals. The nurse manager is accountable for organizing direct and indirect client care functions that necessitate delegation and assignment to competent unit staff, personnel management, quality improvement of client care, and system coordination to achieve agency goals. The other options are all components of professional nursing practice. Question: A hospitalized 5-year-old boy recovering from surgery refuses to drink fluids. Which intervention is best for the nurse to implement? 1. Ask the parents to participate in encouraging the child's fluid intake. 2. Tell the child he can go outside after he drinks a full glass of water. 3. Offer the child a popsicle and allow him to pick the flavor he prefers. 4. Make a game of seeing who can finish a glass of water first--the nurse or the child. 3. Offer the child a popsicle and allow him to pick the flavor he prefers. Fluids in popsicle form are an excellent choice for a child, and small children react best when they are provided with possible choices, such as choosing a flavor. Manipulation should be avoided and the nurse must be careful not to make promises that may not be possible. Question: Which client requires the most immediate intervention by the nurse? 1. A client with low back pain who is experiencing tolerance to the effects of an analgesic. 2. An adolescent with a history of drug addiction who is requesting a sedative. 3. A client with a chronic renal disease who is demonstrating a therapeutic response to a diuretic. 4. A young adult who is reporting an anaphylactic response to an antibiotic. 4. A young adult who is reporting an anaphylactic response to an antibiotic. An anaphylactic response is a severe allergic reaction that may result in airway constriction and shock, so the nurse should first respond to this potentially life-threatening situation. Question: A male client, who has a 3-year history of Type 2 diabetes that is controlled by diet, is being discharged postmyocardial infarction with a prescription of nitroglycerin tablets for chest pain and regular insulin for treatment of his diabetes. Following teaching, the client tells the nurse that he will make sure he keeps his nitroglycerin bottle in his pants pocket at all times, that he eats and drinks a snack before going to bed, and that he checks his blood glucose before eating in the morning. This client requires further teaching on which subject? 1. Storing nitroglycerin. 2. Fluid intake. 3. Blood glucose monitoring. 4. Diabetic diet. 1. Storing nitroglycerin. Nitroglycerin must be kept in the original dark-tinted, glass, screw-top bottle so that contact with air can be avoided, and keeping it in a pants pocket exposes it to body heat, which can reduce its effectiveness. The client should keep the medication in a jacket pocket, which would reduce direct body contact with the bottle. He should also check the expiration date on the bottle (it is good for 3 months and tingling in the mouth indicates that the drug is fresh). Some people experience a headache when taking nitroglycerin, due to the vasodilatation effect. Question: Which action should the nurse implement when implementing a physical assessment of an older client? 1. Avoid unnecessary touching while interacting with the client. 2. Apply additional pressure to palpate the hepatic edge. 3. Arrange the exam sequence to minimizes position changes. 4. Speak loudly and slowly when telling the client how to assist. 3. Arrange the exam sequence to minimizes position changes. Adaptations of the physical examination sequence that limits the amount of position changes during the exam are often useful for an older adult who may have age-related problems, such as decreased mobility, limited energy, or perceptual changes. Question: A healthcare provider (HCP) asks the nurse to give a medication to a client, and the nurse tells the HCP that the client is allergic to the medication. The HCP says, "Give the medication or I will report this to your supervisor." What response should the nurse provide? 1. Walk away and ignore the threatening statement. 2. Give the prescribed medication and document the situation. 3. Tell the HCP that both of you should talk to the supervisor now. 4. Respond that this client is not assigned to the nurse. 3. Tell the HCP that both of you should talk to the supervisor now. Conflict resolution between staff and HCP is best resolved with a mediator who can address facts, not emotional reactions. Walking away or stating it is not their client ignores the conflict, which may escalate. Giving the medication is unsafe practice. Question: A graduate nurse (GN) tells the RN preceptor, "I need to insert a nasogastric tube, and though I was checked off on this procedure in my nursing school's simulation lab, I have never inserted one on a real person." How should the preceptor respond? 1. "I must see documentation of successful check-off by your school's instructor." 2. "Performing the procedure on a simulator is different from performing it on a real person." 3. "Let's review the procedure, then I will supervise you while you perform the procedure." 4. "I will help you, but we need to inform the client that you are new at doing this." 3. "Let's review the procedure, then I will supervise you while you perform the procedure." Reviewing the procedure with the GN allows the preceptor to assess the GN's knowledge of the procedure, and supervising this first-time procedure is the safest option for the client. Documentation of a simulated experience does not negate the need to supervise the GN's first experience. The GN is already aware of the difference of performing the skill on a real person, which is why the issue was presented to the preceptor. Informing the client that the nurse is new at performing the procedure is not necessary, but reviewing the procedure and supervising the GN is necessary. Question: A client who delivered a 9 pound 2 ounce infant 3 hours ago is experiencing uterine atony. Which action should the nurse implement first? 1. Massage the fundus. 2. Catheterize the bladder. 3. Establish venous access. 4. Prep for surgical intervention. 1. Massage the fundus. The initial management for uterine atony is fundal massage to prevent postpartum hemorrhage. Question: Which action should the nurse implement when using the confrontation technique during a vision exam? 1. Use an ophthalmoscope to watch the client's pupil constrict when a strong light is shown on it. 2. Stand behind the client and direct the client to tell the nurse when an object enters the peripheral field of vision. 3. Show the client a series of four cards with printing of varying sizes and ask which card the client sees most clearly. 4. Sit facing the client and while look directly at the client's face, move an object inward from the periphery. 4. Sit facing the client and while look directly at the client's face, move an object inward from the periphery. Confrontation technique during a vision exam is used to determine peripheral vision, sodirectly facing the client and moving an object inward allows the client to state when the object enters the nasal, temporal, superior, and inferior fields of vision. Using