HESI RN EXIT EXAM NEW

HESI RN EXIT EXAM NEW FILE 150 Questions & Answers {This Questions are most repeated Questions in 2022 Actual exam} 1. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements? "In some instancesthe resultis a retarded bone growth." 2. A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate? Monitor vital signs 3. A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse? Listen quietly without comment 4. The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse's immediate attention? "I am itching all over." 5. A depressed client is experiencing severe insomnia. The health care provider orders trazadone (Desyrel). The nurse tells the client to expect? Relief of insomnia 6. The nurse is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse's immediate attention? Blood glucose of 350 mg/dl 7. Which of the following classifications of medications would be most often used for clients with schizophrenia? Neuroleptics 8. The nurse is teaching administration of albuterol inhalation to an adult with asthma. Which of the following demonstrates proper teaching? "Notify the health care provider if you need the drug more often." 9. The nurse is caring for a client with Parkinson's disease who has developed hallucinations. Which of the following medications that the client is receiving may have been a contributing factor? L-Dopa 10. The nurse is administering albuterol (Proventil) to a child with asthma. Which of the following assessments by the nurse indicate the need for an adjustment of the medication? Apical Pulse of 112 11. A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse’s contribution and begins to find objections to the suggestion. The nurse manager's best response is to Let’s move to the ‘what if…’ as related to these objections for an exploration of spin off ideas. 12. When teaching a client about the use of sublingual nitroglycerin, the nurse should emphasize that which of these is the most common side effect? Headache 13. The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client? Determine if the home health aide's care is consistent with the plan of care 14. An RN from the women’s health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse? A client from a motor vehicle accident with an external fixation device on the leg 15. A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which o staff members should the charge nurse assign the client? RN 16. A charge nurse working in a long term care facility is making out assignments. Which assignment to an unlicensed assistive personnel (UAP), if made by the nurse, requires intervention by the supervisor? Teaching a family intermittent (bolus) feedings via G-tube before discharge 17. Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP? Provide basic hygiene care to all clients on the unit 18. The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to? Unlicensed assistive personnel (UAP) 19. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention? Decrease in chest wall expansion 20. The charge nurse on a cardiac step-down unit makes assignments for the team consisting of an RN, a PN, and an unlicensed assistive person. Which client should be assigned to the PN? A 58 year-old hypertensive with possible angina 21. A client experiences intense anxiety after the home was destroyed by a fire. The client escaped from the fire with only minor injuries. The nurse knows that the most important initial intervention would be to: Determine available community and personal resources 22. The client referred for a mammography questions the nurses about the cancer risks from radiation exposure. What is the appropriate response by the nurse? The radiation from a mammography is equivalent to 1 hour of sun exposure 23. The client with multiple sclerosis has an order to change the nasogastric tube. To promote safety when removing the tube, the nurse should: ask the client to hold a breath 24. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? Risk for infection 25. A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are complaining. As a change agent, the nurse manager should first: Explore how the planning committee evaluated barriers to the plan 26. A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate initial action? Report this immediately to the nurse manager 27. The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate? Administer the medication with a syringe next to the tongue 28. During the initial physical assessment on a client who is a Vietnamese immigrant, the nurse notices small, circular, ecchymotic areas on the client's knees. The best action for the nurse to take is to: Ask the client for more information about the nature of the bruises 29. The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age? Separation anxiety 30. A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age? Death is personified as the bogeyman or devil 31. Which statement describes the use of a decision grid for decision making? It is both a visual and a quantitative method of decision making 32. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition? Drug tolerance 33. The nurse is speaking to a group of parents and school teachers of children about care for children with rheumatic fever. It is a priority to emphasize that: Clumsiness and behavior changes should be reported 34. The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention? Respiratory rate of 32 35. The nurse is taking a health history from parents of a child admitted with possible Reye's Syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye's Syndrome? Varicella 36. A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis? The infant received mechanical ventilation for 2 weeks 37. Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child? My child doesn't like many fruits and vegetables, but she really loves her milk 38. The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasize The importance of walking as much as possible 39. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to: go get a blood pressure check within the next 48 to 72 hours 40. Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? Mild vomiting that progressed to vomiting shooting across the room 41. The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspect of this care is: Humidified air and increased oral fluids 42. A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process? Disruption of fetal glucose supply 43. The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching? I dip his pacifier in honey so he'll take it 44. Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy? Succinylcholine (Anectine) 45. To prevent drug resistance common to tubercle bacilli, the nurse is aware that which of the following agents are usually added to drug therapy? Two anti-tuberculosis drugs 46. The charge nurse reviews the charting of a graduate nurse. Which indicates a need for further education on documentation? Charts some actions in advance of performing them 47. The nurse reviews the comprehensive metabolic panel for a client with an electrolyte imbalance. Which data requires the most immediate intervention by the nurse? Sodium level, 125 mEq/L 48. The outpatient clinic nurse is reviewing phone messages from last night. Which client should the nurse call back first? A women at 30 weeks of gestation who has been diagnosed with mild preeclampsia and is unable to relieve her heartburn 49. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? Excessive CNS stimulation will be reduced. 50. A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client? Spontaneous bruising 51. A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the physician's instructions, understanding that the gait was selected after assessment of the client's: Physical and functional abilities 52. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal: S3 ventricular gallop 53. An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? Check the client’s gag reflex 54. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A myocardial infarction that is free from pain and dysrhythmias 55. The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4year-old child? "I have the 4 year-old hold and help feed the four month-old a bottle inthe kitchen while I make supper." 56. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? Pain related to ischemia 57. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze first? Potassium levels 58. The nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which statement by the mother would indicate the need for further teaching? "The therapy can be discontinued when the spots disappear." 59. The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP? Monitor the client's response to ambulatory activity 60. A polydrug user has been in recovery for 8 months. The client has began skipping breakfast and not eating regular dinners. The client has also started frequenting bars to "see old buddies." The nurse understands that the client’s behavior is a warning sign to indicate that the client may be: headed for relapse 61. The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include: Consistent limit-setting enforced 24 hours per day 62. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first? Encourage her to talk about her view of herself 63. A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present? An open wound on their heel 64. A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child? Eating peanuts 65. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question? "When you can climb 2 flights of stairs without problems, it is generally safe." 66. A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which response by the nurse is correct? Days 17-19 67. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering: Vena caval interruption 68. While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age? 2 years of age 69. While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best? "Is there a reason why you don't want to take your medicine?" 70. A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states," This is not my baby, and I do not want it." The nurse's best response is: ‘You seem upset; tell me what the pregnancy and birth were like for you’ 71. A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time? What does the skin on the testicles look and feel like? 72. The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children? Epiphyseal fractures often interrupt a child's normal growth pattern 73. The nurse is planning to administer otic drops to a 6 year-old child. Which of the following is the correct procedure? Hold the pinna up and back to instill the drops 74. The nurse is assessing a client who has taken haldol (Haloperidol) for several months. Which of the following is a side effect of this medication and must be reported immediately to the health care provider? Dystonic reaction 75. A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal is: Avoid alcohol use during this time 76. A victim of domestic violence states, "If I were better, I would not have been beat." Which feeling best describes what the victim may be experiencing? Self-blame 77. The nurse is providing instructions to a new mother on the proper techniques for breast feeding her infant. Which statement by the mother indicates the need for additional instruction? I can switch to a bottle if I need to take a break from breast feeding 78. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound? Occlusive moist dressing 79. Which type of accidental poisoning would the nurse expect to occur in children under age 6? Oral ingestion 80. A depressed client who has recently been acting suicidal is now more social and energetic than usual. Smilingly he tells the nurse "I’ve made some decisions about my life." What should be the nurse’s initial response? ‘Are you thinking about killing yourself?’ 81. The nursing care plan for a client with decreased adrenal function should include: Limiting visitors 82. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child? Prolonged hypoxemia 83. The RN is planning care at a team meeting for a 2 month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application? Tissue perfusion will be maintained 84. When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority? Risk for injury: hemorrhage 85. A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is; Risk for aspiration related to loss of consciousness 86. Which one of the following statements, if made by the client, indicates teaching about Inderal (propranolol) has been effective? “ I can have a heart attack if I stop this medication suddenly." 87. A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in the plan of care within the initial 24 hours for this client? Wear gown and gloves during client contact 88. The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be: High protein, high calorie, unrestricted fat 89. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which: Lead to dehydration 90. A newborn has hyperbilirubinemia and is undergoing phototherapy with a blanket. Which safety measure is most important during this process? Provide water feedings at least every 2 hours 91. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? Strep throat went through all the children at the day care last month 92. A client expresses anger when the call light is not answered within 5 minutes. The client demanded a blanket. The best response for the nurse to make is: "I see this is frustrating for you. I have a few minutes so let's talk." 93. Upon completing the admission documents, the nurse learns that the87 year-old client does not have an advance directive. What action should the nurse take? Give information about advance directives 94. A client with Guillain Barre is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? Glascow Coma Scale 8, respirations regular 95. A hospitalized female client with mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse? "Don’t say that. If you can’t control yourself, we’ll help you." 96. A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client? Positive result on d-dimer study 97. A nurse has given a client with viral hepatitis instructions about home care. Which of the following statements by the client indicates to the nurse that the client needs further teaching? “I need to eat three meals a day with foods high in protein, fat, and carbs’ 98. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? The flow of life is believed to flow through major pathways or nerve clusters in your body. 99. A middle aged woman talks to the nurse in the health care provider’s office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? Fibroids that cause no problems still need to be taken out 100. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? Improved respiratory status and increased urinary output 101. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? Obtain a health and dietary history 102. A 10 year-old child has a history of epilepsy with tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure would be to: Place the hands or a folded blanket under the head of the child 103. A 2 day-old child with spina bifida and meningomyocele is in the intensive care unit after the initial surgery. As the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the grandparents? Disbelief 104. An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to: open the client's airway 105. The client with amyotrophic lateral sclerosis is scheduled for 160 ml of enteral feeding as a bolus every 4 hours. Before flushing with water the nurse aspirates the feeding tube contents and gets back 180 ml of feeding. What is the next appropriate nursing action? Hold the next feeding 106. A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication? Thiocyanate 107. A mother wants to switch her 9 month-old infant from an iron fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse? Continue with the present formula 108. The mother of a 15 month-old child asks the nurse to explain her child's lab results and how they show her child has iron deficiency anemia. The nurse's best response is: "Your child has less red blood cells that carry oxygen." 109. A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority? Counsel the woman to consent to HIV screening 110. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings? These side effects are common and should subside in a few days 111. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d. The client’s family is alarmed and calls the clinic when "his eyes rolled upward." The nurse recognizes this as what type of side effect? Oculogyric crisis 112. A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis: Elevated creatinine phosphokinase (CPK ) 113. A newly appointed nurse manager is having difficulties with time management. Which advice from an experienced manager should the new manager do initially? Keep a time log of your day in hourly blocks for at least 1 week 114. The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect? Acites 115. A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure: Left heart function 116. A client diagnosed with hepatitis C discusses his health history withthe admitting nurse. The nurse should recognize which statement by the client as the most important? I had a blood transfusion 15 years ago. 117. The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees F for a post-surgical client. The nurse checks on the client’s condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP? Check temperature 15 minutes after hot liquids are taken 118. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? Bed in lowest position, wheels locked, place bed against wall 119. A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate? Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain 120. A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client? Hearing loss 121. A rape victim being treated in the emergency department says to the nurse, "I’m really worried that I’ve got HIV now." What is the appropriate response by the nurse? "Let's talk about the information that you need to determine your risk of contracting HIV." 122. An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl to IM fluphenazine decanoate because of medication noncompliance. What should the nurse teach the client and family about this change in medication regimen? There will continue to be a risk of alcohol and drug interaction 123. In caring for a pregnant woman with gestational diabetes, the nurse should be alert to which finding? A 2-hour postprandial level >120 mg/dL 124. Which vital sign in a pediatric client is most important to report to the primary health care provider? Six-year-old with a heart rate of 130 beats/min 125. A client is admitted with a diagnosis of leukemia. This condition is manifested by which of the following? Hyperplasia of the gums, elevated white blood count, weakness 126. The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)? Obtain a fingerstick blood glucose level. 127. After assessing a 26-year-old client with type 1 diabetes mellitus, which data may indicate that the client is experiencing chronic complications of diabetes? Blood pressure, 159/98 mm Hg 128. The nurse empties a client's urinary drainage from an indwelling Foley catheter. Which finding should be reported to the primary health care provider? 240 mL of urinary output is produced in 12 hours 129. When assessing safety for the older adult, which of the following is of highest priority to the nurse? The client reports a history of repeated falls. 130. When caring for a postsurgical client who has undergone multiple blood transfusions, which serum laboratory finding is of most concern to the nurse? Potassium level, 5.5 mEq/L 131. Which finding should be reported to the primary health care provider when caring for a client who has a continuous bladder irrigation after a transurethral resection of the prostate gland (TURP)? The hemoglobin level is 8.4 g/dL 3 days postoperatively. 132. The nurse in the emergency department is caring for a client with type 1 diabetes mellitus in diabetic ketoacidosis (DKA). Which action should the nurse take first? Start an IV infusion of normal saline. 133. The nurse is caring for a hospitalized client with myasthenia gravis. Which finding requires the most immediate action by the nurse? O2 saturation, 89% 134. The nurse assesses a woman in the emergency room who is in her third trimester of pregnancy. Which finding(s) is (are) indicative of abruptio placentae? (Select all that apply.) Dark red vaginal bleeding Rigid boardlike abdomen Complaints of severe abdominal pain 135. A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should: Document the findings 136. A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information? "Wearing the brace is really important in curing the scoliosis’ 137. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? Watermelon 138. A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? Restlessness and increased mucus production 139. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? Diffuse expiratory wheezing 140. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the unlicensed assistive personnel (UAP)? A client with: an order of enemas until clear prior to colonoscopy 141. A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? The appearance of eyeballs that appear to "pop" out of the client's eye sockets 142. An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask? "Do you become short of breath during your normal daily activities?" 143. The nurse is assessing a healthy child at the 2 year checkup. Which of the following should the nurse report immediately to the health care provider? Height and weight percentiles vary widely 144. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age? Imitation of sounds 145. A nurse is doing pre conceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome? "If I drink, my baby may be harmed before I know I am pregnant." 146. Which type of accidental poisoning would the nurse expect to occur in children under age 6? Oral ingestion 147. At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should: Give the client simple information about what she will be doing 148. Clients taking which of the following drugs are at risk for depression? Steroids 149. A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse? Elbow 150. The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up? A 30 month-old only drinking from a sip cu