Community health rn v2 exit hesi guaranteed a tb guide all 55 q
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral
tube feedings. Which task performed by the UAP requires immediate intervention by the
nurse?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees - -B
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk
for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D).
-When caring for a postsurgical client who has undergone multiple blood transfusions, which
serum laboratory finding is of most concern to the nurse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L - -B
Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher
than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).
-Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine - -A
Rationale:
The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is
not recommended until adolescence (B). Varicella immunization begins at 12 months (C).
Meningococcal vaccine is administered beginning at 2 years (D).
-The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed
assistive personnel (UAP)?
A.Assess the need to change a central line dressing.
B.Obtain a fingerstick blood glucose level.
C.Answer a family member's questions about the client's plan of care.
D.Teach the client side effects to report related to the current medication regimen. - -B
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for
UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP.
, -The nurse is caring for a client with an ischemic stroke who has a prescription for tissue
plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select
all that apply.)
A.Administer aspirin with tissue plasminogen activator (t-PA).
B.Complete the National Institute of Health Stroke Scale (NIHSS).
C.Assess the client for signs of bleeding during and after the infusion.
D.Start t-PA within 6 hours after the onset of stroke symptoms.
E.Initiate multidisciplinary consult for potential rehabilitation. - -B,C,E
Rationale:
Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This
includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of
neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is
contraindicated with t-PA because it increases the risk for bleeding (A). The administration of t-
PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and
within 4.5 hours of symptoms is concurrent for a stroke (D).
-When caring for a client in labor, which finding is most important to report to the primary
health care provider?
A.Maternal heart rate, 90 beats/min.
B.Fetal heart rate, 100 beats/min
C.Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature, 100.0° F - -B
Rationale:
A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the average
FHR at term is 140 beats/min and the normal range is 110 to beats/min 160. The others (A, C,
and D) are normal findings for a woman in labor.
-The nurse is caring for a client with heart failure who develops respiratory distress and coughs
up pink frothy sputum. Which action should the nurse take first?
A.Draw arterial blood gases.
B.Notify the primary health care provider.
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray. - -C
Rationale:
Positioning the patient in a high Fowler's position with dangling feet will decrease further
venous return to the left ventricle (C). The other actions should be performed after the change
in position (A, B, and D).
-A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity,
a shuffling gait, and tremors. Which action by the nurse is most important?A.Administer a dose
of benztropine mesylate (Cogentin) PRN.
B.Determine if the client has increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory hallucinations. - -A
,Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are
extrapyramidal side effects associated with Thorazine. It is most important for the nurse to
administer an anticholinergic such as Cogentin to reverse these effects (A). The others (B, C, D)
may be appropriate interventions but are not as urgent as (A).
-A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse
to continue further assessment of the infant?
A.Two-month-old who is unable to roll from back to abdomen
B.Ten-month-old who cannot sit without support
C.Nine-month-old who cries when his mother leaves the room
D.Eight-month-old who has not yet begun to speak words - -B
Rationale:
As a developmental milestone, infants should sit unsupported by 8 months (B). The milestone
of rolling over is achieved at 5 to 6 months for most infants (A). Stranger anxiety is common
from 7 to 9 months (C). Speaking a few words is expected at about 12 months (D).
-Which intervention should be included in the plan of care for a client admitted to the hospital
with ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal. - -C
Rationale:
A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical
manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could worsen the
condition.
-The nurse is caring for a client with deep vein thrombosis who is on a continuous IV heparin
infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which action should the
nurse take?
A.Increase the rate of the heparin infusion using a nomogram.
B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed rate.
D.Stop the heparin drip and prepare to administer protamine sulfate. - -D
Rationale:
An aPTT more than 100 seconds is a critically high value; therefore, the heparin should be
stopped. The antidote for heparin is protamine sulfate (D). Increasing the rate would increase
the risk for hemorrhage (A). The infusion should be stopped, and vitamin K is the antidote for
warfarin (Coumadin) (B). Keeping the infusion at the current rate would increase the risk for
hemorrhage (C).
, -While assessing a client with recurring chest pain, the unit secretary notifies the nurse that the
client's health care provider is on the telephone. What action should the nurse instruct the unit
secretary to implement?
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit. - -C
Rationale:
Another nurse should be asked to take the phone call (C), which allows the nurse to stay at the
bedside to complete the assessment of the client's chest pain. (A and B) should not be done
during an acute change in the client's condition. Requesting the health care provider (D) to
come to the unit is premature until the nurse completes assessment of the client's status.
-Which instruction(s) should the nurse include in the discharge teaching plan of a male client
who has had a myocardial infarction and who has a new prescription for nitroglycerin (NTG)?
(Select all that apply.)
A.Keep the medication in your pocket so that it can be accessed quickly.
B.Call 911 if chest pain is not relieved after one nitroglycerin.
C.Store the medication in its original container and protect it from light.
D.Activate the emergency medical system after three doses of medication.
E.Do not use within 1 hour of taking sildenafil citrate (Viagra). - -B,C
Rationale:
Emergency action should be taken if chest pain is not relieved after one nitroglycerin tablet (B).
The medication should be kept in the original container to protect from light (C). Keeping the
medication in the shirt pocket provides an environment that is too warm (A). The newest
guidelines recommend calling 911 after one nitroglycerin tablet if chest pain is not relieved (D).
Nitroglycerin and other nitrates should never be taken with Viagra (E).
-The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin
subcutaneously to a client with an elevated blood glucose level. Which procedure is correct?
A.Using one syringe, first insert air into the regular vial and then insert air into the NPH vial.
B.Using one syringe, add the regular insulin into the syringe and then add the NPH insulin.
C.Avoid combining the two insulins because incompatibility could cause an adverse reaction.
D.Administer the regular insulin subcutaneously and then give the NPH IV to prevent a separate
stick. - -B
Rationale:
The regular or "clear" insulin should be withdrawn into the syringe first, followed by the NPH
(B). Air should first be injected into the NPH vial and then air should be inserted into the regular
vial (A). NPH and regular insulin are compatible, and combining will reduce the number of
injections (C). The insulin is ordered subcutaneously and NPH cannot be given IV (D).
-An 8-year-old child is receiving digoxin (Lanoxin) for congestive heart failure (CHF). In
assessing the child, the nurse finds that her apical heart rate is 80 beats/min, she complains of
The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral
tube feedings. Which task performed by the UAP requires immediate intervention by the
nurse?
A.Suctions oral secretions from mouth
B.Positions head of bed flat when changing sheets
C.Takes temperature using the axillary method
D.Keeps head of bed elevated at 30 degrees - -B
Rationale:
Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk
for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D).
-When caring for a postsurgical client who has undergone multiple blood transfusions, which
serum laboratory finding is of most concern to the nurse?
A.Sodium level, 137 mEq/L
B.Potassium level, 5.5 mEq/L
C.Blood urea nitrogen (BUN) level, 18 mg/dL
D.Calcium level, 10 mEq/L - -B
Rationale:
Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher
than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).
-Which vaccination should the nurse administer to a newborn?
A.Hepatitis B
B.Human papilloma virus (HPV)
C.Varicella
D.Meningococcal vaccine - -A
Rationale:
The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is
not recommended until adolescence (B). Varicella immunization begins at 12 months (C).
Meningococcal vaccine is administered beginning at 2 years (D).
-The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed
assistive personnel (UAP)?
A.Assess the need to change a central line dressing.
B.Obtain a fingerstick blood glucose level.
C.Answer a family member's questions about the client's plan of care.
D.Teach the client side effects to report related to the current medication regimen. - -B
Rationale:
Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for
UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP.
, -The nurse is caring for a client with an ischemic stroke who has a prescription for tissue
plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select
all that apply.)
A.Administer aspirin with tissue plasminogen activator (t-PA).
B.Complete the National Institute of Health Stroke Scale (NIHSS).
C.Assess the client for signs of bleeding during and after the infusion.
D.Start t-PA within 6 hours after the onset of stroke symptoms.
E.Initiate multidisciplinary consult for potential rehabilitation. - -B,C,E
Rationale:
Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This
includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of
neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is
contraindicated with t-PA because it increases the risk for bleeding (A). The administration of t-
PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and
within 4.5 hours of symptoms is concurrent for a stroke (D).
-When caring for a client in labor, which finding is most important to report to the primary
health care provider?
A.Maternal heart rate, 90 beats/min.
B.Fetal heart rate, 100 beats/min
C.Maternal blood pressure, 140/86 mm Hg
D.Maternal temperature, 100.0° F - -B
Rationale:
A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the average
FHR at term is 140 beats/min and the normal range is 110 to beats/min 160. The others (A, C,
and D) are normal findings for a woman in labor.
-The nurse is caring for a client with heart failure who develops respiratory distress and coughs
up pink frothy sputum. Which action should the nurse take first?
A.Draw arterial blood gases.
B.Notify the primary health care provider.
C.Position in a high Fowler's position with the legs down.
D.Obtain a chest X-ray. - -C
Rationale:
Positioning the patient in a high Fowler's position with dangling feet will decrease further
venous return to the left ventricle (C). The other actions should be performed after the change
in position (A, B, and D).
-A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity,
a shuffling gait, and tremors. Which action by the nurse is most important?A.Administer a dose
of benztropine mesylate (Cogentin) PRN.
B.Determine if the client has increased photosensitivity.
C.Provide comfort measures for sore muscles.
D.Assess the client for visual and auditory hallucinations. - -A
,Rationale:
Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are
extrapyramidal side effects associated with Thorazine. It is most important for the nurse to
administer an anticholinergic such as Cogentin to reverse these effects (A). The others (B, C, D)
may be appropriate interventions but are not as urgent as (A).
-A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse
to continue further assessment of the infant?
A.Two-month-old who is unable to roll from back to abdomen
B.Ten-month-old who cannot sit without support
C.Nine-month-old who cries when his mother leaves the room
D.Eight-month-old who has not yet begun to speak words - -B
Rationale:
As a developmental milestone, infants should sit unsupported by 8 months (B). The milestone
of rolling over is achieved at 5 to 6 months for most infants (A). Stranger anxiety is common
from 7 to 9 months (C). Speaking a few words is expected at about 12 months (D).
-Which intervention should be included in the plan of care for a client admitted to the hospital
with ulcerative colitis?
A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal. - -C
Rationale:
A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical
manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could worsen the
condition.
-The nurse is caring for a client with deep vein thrombosis who is on a continuous IV heparin
infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which action should the
nurse take?
A.Increase the rate of the heparin infusion using a nomogram.
B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed rate.
D.Stop the heparin drip and prepare to administer protamine sulfate. - -D
Rationale:
An aPTT more than 100 seconds is a critically high value; therefore, the heparin should be
stopped. The antidote for heparin is protamine sulfate (D). Increasing the rate would increase
the risk for hemorrhage (A). The infusion should be stopped, and vitamin K is the antidote for
warfarin (Coumadin) (B). Keeping the infusion at the current rate would increase the risk for
hemorrhage (C).
, -While assessing a client with recurring chest pain, the unit secretary notifies the nurse that the
client's health care provider is on the telephone. What action should the nurse instruct the unit
secretary to implement?
A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit. - -C
Rationale:
Another nurse should be asked to take the phone call (C), which allows the nurse to stay at the
bedside to complete the assessment of the client's chest pain. (A and B) should not be done
during an acute change in the client's condition. Requesting the health care provider (D) to
come to the unit is premature until the nurse completes assessment of the client's status.
-Which instruction(s) should the nurse include in the discharge teaching plan of a male client
who has had a myocardial infarction and who has a new prescription for nitroglycerin (NTG)?
(Select all that apply.)
A.Keep the medication in your pocket so that it can be accessed quickly.
B.Call 911 if chest pain is not relieved after one nitroglycerin.
C.Store the medication in its original container and protect it from light.
D.Activate the emergency medical system after three doses of medication.
E.Do not use within 1 hour of taking sildenafil citrate (Viagra). - -B,C
Rationale:
Emergency action should be taken if chest pain is not relieved after one nitroglycerin tablet (B).
The medication should be kept in the original container to protect from light (C). Keeping the
medication in the shirt pocket provides an environment that is too warm (A). The newest
guidelines recommend calling 911 after one nitroglycerin tablet if chest pain is not relieved (D).
Nitroglycerin and other nitrates should never be taken with Viagra (E).
-The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin
subcutaneously to a client with an elevated blood glucose level. Which procedure is correct?
A.Using one syringe, first insert air into the regular vial and then insert air into the NPH vial.
B.Using one syringe, add the regular insulin into the syringe and then add the NPH insulin.
C.Avoid combining the two insulins because incompatibility could cause an adverse reaction.
D.Administer the regular insulin subcutaneously and then give the NPH IV to prevent a separate
stick. - -B
Rationale:
The regular or "clear" insulin should be withdrawn into the syringe first, followed by the NPH
(B). Air should first be injected into the NPH vial and then air should be inserted into the regular
vial (A). NPH and regular insulin are compatible, and combining will reduce the number of
injections (C). The insulin is ordered subcutaneously and NPH cannot be given IV (D).
-An 8-year-old child is receiving digoxin (Lanoxin) for congestive heart failure (CHF). In
assessing the child, the nurse finds that her apical heart rate is 80 beats/min, she complains of
