EXIT HESI -PN EXAM A PRACTICE
QUESTION AND ANSWERS
Avgnursevgwhovghasvgrecentlyvgcompletedvgorientationvgisvgbeginningvgworkvginvgthevglaborv
gandvgdeliveryvgunitvgforvgthevgfirstvgtime.vgWhenvgmakingvgassignments,vgwhichvgclientvgsh
ouldvgthevgchargevgnursevgassignvgtovgthisvgnewvgnurse?
A.Avgprimigravidavgwhovgisvg8vgcmvgdilatedvgaftervg14vghoursvgofvglabor
vgB.Avgclientvgscheduledvgforvgavgrepeatvgcesareanvgbirthvgatvg38vgweeks'vggestation
vgC.Avgclientvgbeingvginducedvgforvgfetalvgdemisevgatvg20vgweeks'vggestation
vgD.Avgmultiparousvgclientvgwhovgisvgdilatedvg5vgcmvgandvg50%vgeffacedvg-vganswer--D
Thevgnewvgnursevgshouldvgbevgassignedvgthevgleastvgcomplicatedvgclientvgtovggainvgexperi
encevgandvgconfidence,vgasvgwellvgasvgprotectvgclientvgsafety.vgOfvgthevgclientsvgavailablevgf
orvgassignment,vg(D)vgisvgprogressingvgwellvgandvgisvgthevgleastvgcomplicated.vg(A,vgBvgandv
gC)vghavevgactualvgorvgpotentialvgcomplicationsvgandvgshouldvgbevgassignedvgtovgavgmorevg
experiencedvgnurse.
Avgclientvgwithvghumanvgimmunodeficiencyvgvirusvg(HIV)vginfectionvghasvgwhitevglesionsvgi
nvgthevgoralvgcavityvgthatvgresemblevgmilkvgcurds.vgNystatinvg(Mycostatin)vgpreparationvgisv
gprescribedvgasvgavgswishvgandvgswallow.vgWhichvginformationvgisvgmostvgimportantvgforvgt
hevgnursevgtovgprovidevgthevgclient?
A.Oralvghygienevgshouldvgbevgperformedvgbeforevgthevgmedication.vgB.Antifungalvgmedic
ationsvgarevgavailablevginvgtablet,vgsuppository,vgandvgliquidvgforms.
vgC.Candidavgalbicansvgisvgthevgorganismvgthatvgcausesvgthevgwhitevglesionsvginvgthevgmout
h.
vgD.Thevgdietaryvgintakevgofvgdairyvgandvgspicyvgfoodsvgshouldvgbevglimited.vg-vganswer--A
HIVvginfectionvgcausesvgdepressionvgofvgcell-
mediatedvgimmunityvgthatvgallowsvganvgovergrowthvgofvgCandidavgalbicansvg(oralvgmonilia
sis),vgwhichvgappearsvgasvgwhite,vgcheesyvgplaquevgorvglesionsvgthatvgresemblevgmilkvgcur
ds.vgTovgensurevgeffectivevgcontactvgofvgthevgmedicationvgwithvgthevgoralvglesions,vgoralvgliq
uidsvgshouldvgbevgconsumedvgandvgoralvghygienevgperformedvgbeforevgswishingvgthevgliqui
dvgMycostatinvg(A).vg(BvgandvgC)vgprovidevgthevgclientvgwithvgadditionalvginformationvgabout
vgthevgpathogenesisvgandvgtreatmentvgofvgopportunisticvginfections,vgbutvg(A)vgallowsvgthevg
clientvgtovgparticipatevginvgself-
carevgofvgthevgoralvginfection.vgDietaryvgrestrictionvgofvgspicyvgfoodsvgreducesvgdiscomfortvg
associatedvgwithvgstomatitis,vgbutvgrestrictionvgofvgdairyvgproductsvgisvgnotvgindicatedvg(D).
Avgclientvgwhovgisvgadmittedvgwithvgemphysemavgisvghavingvgdifficultyvgbreathing.vgInvgwhic
hvgpositionvgshouldvgthevgnursevgplacevgthevgclient?
A.HighvgFowler'svgpositionvgwithoutvgavgpillowvgbehindvgthevghead
vgB.Semi-Fowler'svgpositionvgwithvgavgsinglevgpillowvgbehindvgthevghead
vgC.Rightvgside-lyingvgpositionvgwithvgthevgheadvgofvgthevgbedvgelevatedvg45vgdegrees
,vgD.Sittingvguprightvgandvgforwardvgwithvgbothvgarmsvgsupportedvgonvganvgovervgthevgbedvgt
ablevg-vganswer--D
Adequatevglungvgexpansionvgisvgdependentvgonvgdeepvgbreathsvgthatvgallowvgthevgrespirat
oryvgmusclesvgtovgincreasevgthevglongitudinalvgandvganterior-
posteriorvgsizevgofvgthevgthoracicvgcage.vgSittingvguprightvgandvgleaningvgforwardvgwithvgthe
vgarmsvgsupportedvgonvganvgovervgthevgbedvgtablevg(D)vgallowsvgthevgthoracicvgcagevgtovgex
pandvginvgallvgfourvgdirectionsvgandvgreducesvgdyspnea.vgAvghighvgFowler'svgpositionvgdoes
vgnotvgallowvgmaximumvgexpansionvgofvgthevgposteriorvglobesvgofvgthevglungsvg(A).vgAvgsemi
-Fowler'svgpositionvgrestrictsvgexpansionvgofvgthevganterior-
posteriorvgdiametervgofvgthevgthoracicvgcagevg(B).vgPositioningvgavgclientvgonvgthevgrightvgsi
devgwithvgthevgheadvgofvgthevgbedvgelevatedvg(C)vgdoesvgnotvgfacilitatevglungvgexpansion.
Avgclientvgwithvgchronicvgrenalvginsufficiencyvg(CRI)vgisvgtakingvg25vgmgvgofvghydrochlorothi
azidevg(HCTZ)vgPOvgandvg40vgmgvgofvgfurosemidevg(Lasix)vgPOvgdaily.vgToday,vgatvgavgrout
inevgclinicvgvisit,vgthevgclient'svgserumvgpotassiumvglevelvgisvg4vgmEq/
L.vgWhatvgisvgthevgmostvglikelyvgcausevgofvgthisvgclient'svgpotassiumvglevel?
A.Thevgclientvgisvgnoncompliantvgwithvghisvgmedications.
vgB.Thevgclientvgrecentlyvgconsumedvglargevgquantitiesvgofvgpearsvgorvgnuts.
vgC.Thevgclient'svgrenalvgfunctionvghasvgaffectedvghisvgpotassiumvglevel.
vgD.Thevgclientvgneedsvgtovgbevgstartedvgonvgavgpotassiumvgsupplement.vg-vganswer--C
Thevgclientvghasvgavgnormalizedvgpotassiumvglevelvgdespitevgdiureticvgusevg(C).vgThevgkidn
eyvgautomaticallyvgsecretesvg90%vgofvgpotassiumvgconsumed,vgbutvginvgchronicvgrenalvgin
sufficiencyvg(CRI),vglessvgpotassiumvgisvgexcretedvgthanvgnormal.vgTherefore,vgthevgtwovgp
otassium-
wastingvgdrugs,vgavgthiazidevgdiureticvgandvgloopvgdiuretic,vgarevgnotvglikelyvgtovgaffectvgpot
assiumvglevels.vgThevgnormalvgpotassiumvglevelvgisvg3.5vgtovg5vgmEq/
L,vgandvgwithvgavgpotassiumvglevelvgofvg4vgmEq/
L,vgtherevgisvgnovgreasonvgtovgbelievevgthatvgthevgclientvgisvgnoncompliantvgwithvghisvgtreatm
entvg(A).vgPearsvgandvgnutsvgdovgnotvgaffectvgthevgserumvgpotassiumvglevelvg(B).vgTherevgisv
gnovgneedvgforvgavgpotassiumvgsupplementvg(D)vgbecausevgthevgclient'svgpotassiumvglevelv
gisvgwithinvgthevgnormalvgrange.
Avgregisteredvgnursevg(RN)vgdeliversvgtelehealthvgservicesvgtovgclientsvgviavgelectronicvgco
mmunication.vgWhichvgnursingvgactionvgcreatesvgthevggreatestvgriskvgforvgprofessionalvglia
bilityvgandvghasvgthevgpotentialvgforvgavgmalpracticevglawsuit?
A.Participatingvginvgtelephonevgconsultationsvgwithvgclients
vgB.Identifyingvgoneselfvgbyvgnamevgandvgtitlevgtovgclientsvginvgtelehealthvgcommunications
vgC.SendingvgmedicalvgrecordsvgtovghealthvgcarevgprovidersvgviavgthevgInternet
vgD.Answeringvgavgclient-initiatedvghealthvgquestionvgviavgelectronicvgmailvg-vganswer--C
SendingvgmedicalvgrecordsvgovervgthevgInternet,vgevenvgwithvgthevglatestvgsecurityvgprotect
ion,vgcreatesvgthevggreatestvgriskvgforvgliabilityvgbecausevgofvgthevghighvgpotentialvgofvgbreac
hingvgclientvgconfidentialityvgandvgthevgamountvgofvginformationvgbeingvgtransferredvg(C).vg
Clientvgconfidentialityvgisvgprotectedvgbyvgfederalvgwiretappingvglawsvgmakingvgtelephonev
gconsultationvg(A)vgavgprivatevgandvgprotectedvgformvgofvgcommunication.vgByvgstatingvgon
e'svgnamevgandvgcredentialsvginvgtelehealthvgcommunicationvg(B),vgonevgisvgtakingvgrespo
nsibilityvgforvgthevgencounter.vgE-
mailvginitiatedvgbyvgthevgclientvg(D)vgposesvglessvgriskvgthanvgsendingvgrecordsvgviavgthevgInt
ernet.
,Whichvgpathophysiologicvgresponsevgsupportsvgthevgcontraindicationvgforvgopioids,vgsuch
vgasvgmorphine,vginvgclientsvgwithvgincreasedvgintracranialvgpressurevg(ICP)?
A.Sedationvgproducedvgbyvgopioidsvgisvgavgresultvgofvgavgprolongedvghalf-
lifevgwhenvgthevgICPvgisvgelevated.
vgB.Highervgdosesvgofvgopioidsvgarevgrequiredvgwhenvgcerebralvgbloodvgflowvgisvgreducedvg
byvganvgelevatedvgICP.
vgC.Dysphoriavgfromvgopioidsvgcontributesvgtovgalteredvglevelsvgofvgconsciousnessvgwithvga
nvgelevatedvgICP.
D.Opioidsvgsuppressvgrespirations,vgwhichvgincreasesvgPco2vgandvgcontributesvgtovganvgel
evatedvgICP.vg-vganswer--D
Thevggreatestvgriskvgassociatedvgwithvgopioidsvgsuchvgasvgmorphinevg(D)vgisvgrespiratoryvg
depressionvgthatvgcausesvganvgincreasevginvgPco2,vgwhichvgincreasesvgICPvgandvgmasksvg
thevgearlyvgsignsvgofvgintracranialvgbleedingvginvgheadvginjury.vg(A,vgB,vgandvgC)vgdovgnotvgsu
pportvgthevgrisksvgassociatedvgwithvgopioidvgusevginvgavgclientvgwithvgincreasedvgICP.
Thevgchargevgnursevgofvgavgmedicalvgsurgicalvgunitvgisvgalertedvgtovganvgimpendingvgdisaste
rvgrequiringvgimplementationvgofvgthevghospital'svgdisastervgplan.vgSpecificvgfactsvgaboutvgt
hevgnaturevgofvgthisvgdisastervgarevgnotvgyetvgknown.vgWhichvginstructionvgshouldvgthevgcha
rgevgnursevggivevgtovgthevgothervgstaffvgmembersvgatvgthisvgtime?
A.Preparevgtovgevacuatevgthevgunit,vgstartingvgwithvgthevgbedriddenvgclients.
vgB.UAPsvgshouldvgreportvgtovgthevgemergencyvgcentervgtovghandlevgtransports.
vgC.ThevglicensedvgstaffvgshouldvgbeginvgcountingvgwheelchairsvgandvgIVvgpolesvgonvgthevg
unit.
vgD.Continuevgwithvgcurrentvgassignments vguntilvgmorevginstructionsvgarevgreceived.vg-
vganswer--D
Whenvgfacedvgwithvganvgimpendingvgdisaster,vghospitalvgpersonnelvgmayvgbevgalertedvgbut
vgshouldvgcontinuevgwithvgcurrentvgclientvgcarevgassignments vguntilvgfurthervginstructionsvg
arevgreceivedvg(D).vgEvacuationvgisvgtypicallyvgavgresponsevgofvglastvgresortvgthatvgbeginsvg
withvgclientsvgwhovgarevgmostvgablevgtovgambulatevg(A).vg(B)vgisvgprematurevgandvgisvglikelyv
gtovgincreasevgthevgchaosvgifvgincomingvgcasualtiesvgarevganticipated.vg(C)vgisvgpoorvgutiliza
tionvgofvgpersonnel.
ThevgnursevgassessesvgavgclientvgwhilevgthevgUAPvgmeasuresvgthevgclient'svgvitalvgsigns.vg
Thevgclient'svgvitalvgsignsvgchangevgsuddenly,vgandvgthevgnursevgdeterminesvgthatvgthevgcli
ent'svgconditionvgisvgworsening.vgThevgnursevgisvgunsurevgofvgthevgclient'svgresuscitativevgst
atusvgandvgneedsvgtovgcheckvgthevgclient'svgmedicalvgrecordvgforvganyvgadvancedvgdirectiv
es.vgWhichvgactionvgshouldvgthevgnursevgimplement?
A.AskvgthevgUAPvgtovgcheckvgforvgthevgadvancedvgdirectivevgwhilevgthevgnursevgcompletesv
gthevgassessment.
B.AssignvgthevgUAPvgtovgcompletevgthevgassessmentvgwhilevgthevgnursevgchecksvgforvgthev
gadvancedvgdirective.
C.Checkvgthevgmedicalvgrecordvgforvgthevgadvancedvgdirectivevgandvgthenvgcompletevgthevg
clientvgassessment.
vgD.Callvgforvgthevgchargevgnursevgtovgcheckvgthevgadvancedvgdirectivevgwhilevgcontinuingvg
tovgassessvgthevgclient.vg-vganswer--D
, Becausevgthevgclient'svgconditionvgisvgworsening,vgthevgnursevgshouldvgremainvgwithvgthevg
clientvgandvgcontinuevgthevgassessmentvgwhilevgcallingvgforvghelpvgfromvgthevgchargevgnurs
evgtovgdeterminevgthevgclient'svgresuscitativevgstatusvg(D).vg(AvgandvgB)vgarevgtasksvgthatvgm
ustvgbevgcompletedvgbyvgavgnursevgandvgcannotvgbevgdelegatedvgtovgthevgUAP.vg(C)vgisvgcon
traindicated.
Thevgnursevgisvgpreparingvgavgclientvgforvgsurgeryvgscheduledvginvg2vghours.vgAvgUAPvgisvgh
elpingvgthevgnurse.vgWhichvgtaskvgisvgimportantvgforvgthevgnursevgtovgperform,vgrathervgthan
vgthevgUAP?
A.Removevgthevgclient'svgnailvgpolishvgandvgdentures.
vgB.Assistvgthevgclientvgtovgthevgrestroomvgtovgvoid.
vgC.Obtainvgthevgclient'svgheightvgandvgweight.
vgD.Offervgthevgclientvgemotionalvgsupport.vg-vganswer--D
Byvgusingvgtherapeuticvgtechniquesvgtovgoffervgsupportvg(D),vgthevgnursevgcanvgdeterminevg
anyvgclientvgconcernsvgthatvgneedvgtovgbevgaddressed.vg(A,vgB,vgandvgC)vgarevgallvgactionsvgt
hatvgcanvgbevgperformedvgbyvgthevgUAPvgundervgthevgsupervisionvgofvgthevgnurse.
Untilvgthevgcensusvgonvgthevgobstetricsvg(OB)vgunitvgincreases,vganvgunlicensedvgassistivev
gpersonnelvg(UAP)vgwhovgusuallyvgworksvginvglaborvgandvgdeliveryvgandvgthevgnewbornvgnu
rseryvgisvgassignedvgtovgworkvgonvgthevgpostoperativevgunit.vgWhichvgclientvgwouldvgbevgbe
stvgforvgthevgchargevgnursevgtovgassignvgtovgthisvgUAP?
vgA.Anvgadolescentvgwhovgwasvgreadmittedvgtovgthevghospitalvgbecausevgofvgavgpostoperati
vevginfection
vgB.Avgwomanvgwithvgavgnewvgcolostomyvgwhovgrequiresvgdischargevgteaching
vgC.Avgwomanvgwhovghadvgavghipvgreplacementvgandvgmayvgbevgtransferredvgtovgthevghome
vgcarevgunit
vgD.Avgmanvgwhovghadvgavgcholecystectomyvgandvgcurrentlyvghasvgavgnasogastricvgtubevgs
etvgtovgintermittentvgsuctionvg-vganswer--C
Thevgchargevgnursevgwillvgbevgresponsiblevgforvgprovidingvgavgreportvgtovgthevghomevgcarevg
unitvgifvgthevgtransfervgoccursvg(A).vgThevgclientvgisvginfectedvgandvganvgemployeevgwhovgwo
rksvgonvganvgOBvgunitvgshouldvgbevgassignedvgtovgcleanvgcasesvginvgcasevgthevgemployeevgi
svgrequiredvgtovgreturnvgtovgthevgOBvgunitvg(B).vgThisvgrequiresvgthevgskillsvgofvgavgregisteredv
gnursevg(RN)vgtovgdovgdischargevgteachingvgandvgprovidevgemotionalvgsupportvg(D).vgThisvg
mayvgrequirevgskillsvgbeyondvgthevglevelvgofvgthisvgUAP.
Avgmalevgclientvgisvgadmittedvgforvgobservationvgaftervgbeingvghitvgonvgthevgheadvgwithvgavgb
aseballvgbat.vgSixvghoursvgaftervgadmission,vgthevgclientvgattemptsvgtovgcrawlvgoutvgofvgbedvg
andvgasksvgthevgnursevgwhyvgtherevgarevgsovgmanyvgbugsvginvghisvgbed.vgHisvgvitalvgsignsvga
revgstable,vgandvgthevgpulsevgoximetervgreadingvgisvg98%vgonvgroomvgair.vgWhichvgintervent
ionvgshouldvgthevgnursevgperformvgfirst?
A.Administervgoxygenvgpervgnasalvgcannulavgatvg2vgL/min.
B.Planvgtovgcheckvghisvgvitalvgsignsvgagainvginvg30vgminutes.
C.Notifyvgthevghealthvgcarevgprovidervgofvgthevgchangevginvgmentalvgstatus.
D.Askvgthevgclientvgwhyvghevgthinksvgtherevgarevgbugsvginvgthevgbed.vg-vganswer--C
Onevgofvgthevgearliestvgsignsvgofvgincreasedvgintracranialvgpressurevg(ICP)vgisvgavgchangevg
invgmentalvgstatusvg(C).vgItvgisvgimportantvgtovgactvgearlyvgandvgquicklyvgwhenvgsymptomsvgo
fvgincreasedvgICPvgoccur.vgBecausevghisvgoxygenvgsaturationvgisvgnormal,vgthevgadministr
QUESTION AND ANSWERS
Avgnursevgwhovghasvgrecentlyvgcompletedvgorientationvgisvgbeginningvgworkvginvgthevglaborv
gandvgdeliveryvgunitvgforvgthevgfirstvgtime.vgWhenvgmakingvgassignments,vgwhichvgclientvgsh
ouldvgthevgchargevgnursevgassignvgtovgthisvgnewvgnurse?
A.Avgprimigravidavgwhovgisvg8vgcmvgdilatedvgaftervg14vghoursvgofvglabor
vgB.Avgclientvgscheduledvgforvgavgrepeatvgcesareanvgbirthvgatvg38vgweeks'vggestation
vgC.Avgclientvgbeingvginducedvgforvgfetalvgdemisevgatvg20vgweeks'vggestation
vgD.Avgmultiparousvgclientvgwhovgisvgdilatedvg5vgcmvgandvg50%vgeffacedvg-vganswer--D
Thevgnewvgnursevgshouldvgbevgassignedvgthevgleastvgcomplicatedvgclientvgtovggainvgexperi
encevgandvgconfidence,vgasvgwellvgasvgprotectvgclientvgsafety.vgOfvgthevgclientsvgavailablevgf
orvgassignment,vg(D)vgisvgprogressingvgwellvgandvgisvgthevgleastvgcomplicated.vg(A,vgBvgandv
gC)vghavevgactualvgorvgpotentialvgcomplicationsvgandvgshouldvgbevgassignedvgtovgavgmorevg
experiencedvgnurse.
Avgclientvgwithvghumanvgimmunodeficiencyvgvirusvg(HIV)vginfectionvghasvgwhitevglesionsvgi
nvgthevgoralvgcavityvgthatvgresemblevgmilkvgcurds.vgNystatinvg(Mycostatin)vgpreparationvgisv
gprescribedvgasvgavgswishvgandvgswallow.vgWhichvginformationvgisvgmostvgimportantvgforvgt
hevgnursevgtovgprovidevgthevgclient?
A.Oralvghygienevgshouldvgbevgperformedvgbeforevgthevgmedication.vgB.Antifungalvgmedic
ationsvgarevgavailablevginvgtablet,vgsuppository,vgandvgliquidvgforms.
vgC.Candidavgalbicansvgisvgthevgorganismvgthatvgcausesvgthevgwhitevglesionsvginvgthevgmout
h.
vgD.Thevgdietaryvgintakevgofvgdairyvgandvgspicyvgfoodsvgshouldvgbevglimited.vg-vganswer--A
HIVvginfectionvgcausesvgdepressionvgofvgcell-
mediatedvgimmunityvgthatvgallowsvganvgovergrowthvgofvgCandidavgalbicansvg(oralvgmonilia
sis),vgwhichvgappearsvgasvgwhite,vgcheesyvgplaquevgorvglesionsvgthatvgresemblevgmilkvgcur
ds.vgTovgensurevgeffectivevgcontactvgofvgthevgmedicationvgwithvgthevgoralvglesions,vgoralvgliq
uidsvgshouldvgbevgconsumedvgandvgoralvghygienevgperformedvgbeforevgswishingvgthevgliqui
dvgMycostatinvg(A).vg(BvgandvgC)vgprovidevgthevgclientvgwithvgadditionalvginformationvgabout
vgthevgpathogenesisvgandvgtreatmentvgofvgopportunisticvginfections,vgbutvg(A)vgallowsvgthevg
clientvgtovgparticipatevginvgself-
carevgofvgthevgoralvginfection.vgDietaryvgrestrictionvgofvgspicyvgfoodsvgreducesvgdiscomfortvg
associatedvgwithvgstomatitis,vgbutvgrestrictionvgofvgdairyvgproductsvgisvgnotvgindicatedvg(D).
Avgclientvgwhovgisvgadmittedvgwithvgemphysemavgisvghavingvgdifficultyvgbreathing.vgInvgwhic
hvgpositionvgshouldvgthevgnursevgplacevgthevgclient?
A.HighvgFowler'svgpositionvgwithoutvgavgpillowvgbehindvgthevghead
vgB.Semi-Fowler'svgpositionvgwithvgavgsinglevgpillowvgbehindvgthevghead
vgC.Rightvgside-lyingvgpositionvgwithvgthevgheadvgofvgthevgbedvgelevatedvg45vgdegrees
,vgD.Sittingvguprightvgandvgforwardvgwithvgbothvgarmsvgsupportedvgonvganvgovervgthevgbedvgt
ablevg-vganswer--D
Adequatevglungvgexpansionvgisvgdependentvgonvgdeepvgbreathsvgthatvgallowvgthevgrespirat
oryvgmusclesvgtovgincreasevgthevglongitudinalvgandvganterior-
posteriorvgsizevgofvgthevgthoracicvgcage.vgSittingvguprightvgandvgleaningvgforwardvgwithvgthe
vgarmsvgsupportedvgonvganvgovervgthevgbedvgtablevg(D)vgallowsvgthevgthoracicvgcagevgtovgex
pandvginvgallvgfourvgdirectionsvgandvgreducesvgdyspnea.vgAvghighvgFowler'svgpositionvgdoes
vgnotvgallowvgmaximumvgexpansionvgofvgthevgposteriorvglobesvgofvgthevglungsvg(A).vgAvgsemi
-Fowler'svgpositionvgrestrictsvgexpansionvgofvgthevganterior-
posteriorvgdiametervgofvgthevgthoracicvgcagevg(B).vgPositioningvgavgclientvgonvgthevgrightvgsi
devgwithvgthevgheadvgofvgthevgbedvgelevatedvg(C)vgdoesvgnotvgfacilitatevglungvgexpansion.
Avgclientvgwithvgchronicvgrenalvginsufficiencyvg(CRI)vgisvgtakingvg25vgmgvgofvghydrochlorothi
azidevg(HCTZ)vgPOvgandvg40vgmgvgofvgfurosemidevg(Lasix)vgPOvgdaily.vgToday,vgatvgavgrout
inevgclinicvgvisit,vgthevgclient'svgserumvgpotassiumvglevelvgisvg4vgmEq/
L.vgWhatvgisvgthevgmostvglikelyvgcausevgofvgthisvgclient'svgpotassiumvglevel?
A.Thevgclientvgisvgnoncompliantvgwithvghisvgmedications.
vgB.Thevgclientvgrecentlyvgconsumedvglargevgquantitiesvgofvgpearsvgorvgnuts.
vgC.Thevgclient'svgrenalvgfunctionvghasvgaffectedvghisvgpotassiumvglevel.
vgD.Thevgclientvgneedsvgtovgbevgstartedvgonvgavgpotassiumvgsupplement.vg-vganswer--C
Thevgclientvghasvgavgnormalizedvgpotassiumvglevelvgdespitevgdiureticvgusevg(C).vgThevgkidn
eyvgautomaticallyvgsecretesvg90%vgofvgpotassiumvgconsumed,vgbutvginvgchronicvgrenalvgin
sufficiencyvg(CRI),vglessvgpotassiumvgisvgexcretedvgthanvgnormal.vgTherefore,vgthevgtwovgp
otassium-
wastingvgdrugs,vgavgthiazidevgdiureticvgandvgloopvgdiuretic,vgarevgnotvglikelyvgtovgaffectvgpot
assiumvglevels.vgThevgnormalvgpotassiumvglevelvgisvg3.5vgtovg5vgmEq/
L,vgandvgwithvgavgpotassiumvglevelvgofvg4vgmEq/
L,vgtherevgisvgnovgreasonvgtovgbelievevgthatvgthevgclientvgisvgnoncompliantvgwithvghisvgtreatm
entvg(A).vgPearsvgandvgnutsvgdovgnotvgaffectvgthevgserumvgpotassiumvglevelvg(B).vgTherevgisv
gnovgneedvgforvgavgpotassiumvgsupplementvg(D)vgbecausevgthevgclient'svgpotassiumvglevelv
gisvgwithinvgthevgnormalvgrange.
Avgregisteredvgnursevg(RN)vgdeliversvgtelehealthvgservicesvgtovgclientsvgviavgelectronicvgco
mmunication.vgWhichvgnursingvgactionvgcreatesvgthevggreatestvgriskvgforvgprofessionalvglia
bilityvgandvghasvgthevgpotentialvgforvgavgmalpracticevglawsuit?
A.Participatingvginvgtelephonevgconsultationsvgwithvgclients
vgB.Identifyingvgoneselfvgbyvgnamevgandvgtitlevgtovgclientsvginvgtelehealthvgcommunications
vgC.SendingvgmedicalvgrecordsvgtovghealthvgcarevgprovidersvgviavgthevgInternet
vgD.Answeringvgavgclient-initiatedvghealthvgquestionvgviavgelectronicvgmailvg-vganswer--C
SendingvgmedicalvgrecordsvgovervgthevgInternet,vgevenvgwithvgthevglatestvgsecurityvgprotect
ion,vgcreatesvgthevggreatestvgriskvgforvgliabilityvgbecausevgofvgthevghighvgpotentialvgofvgbreac
hingvgclientvgconfidentialityvgandvgthevgamountvgofvginformationvgbeingvgtransferredvg(C).vg
Clientvgconfidentialityvgisvgprotectedvgbyvgfederalvgwiretappingvglawsvgmakingvgtelephonev
gconsultationvg(A)vgavgprivatevgandvgprotectedvgformvgofvgcommunication.vgByvgstatingvgon
e'svgnamevgandvgcredentialsvginvgtelehealthvgcommunicationvg(B),vgonevgisvgtakingvgrespo
nsibilityvgforvgthevgencounter.vgE-
mailvginitiatedvgbyvgthevgclientvg(D)vgposesvglessvgriskvgthanvgsendingvgrecordsvgviavgthevgInt
ernet.
,Whichvgpathophysiologicvgresponsevgsupportsvgthevgcontraindicationvgforvgopioids,vgsuch
vgasvgmorphine,vginvgclientsvgwithvgincreasedvgintracranialvgpressurevg(ICP)?
A.Sedationvgproducedvgbyvgopioidsvgisvgavgresultvgofvgavgprolongedvghalf-
lifevgwhenvgthevgICPvgisvgelevated.
vgB.Highervgdosesvgofvgopioidsvgarevgrequiredvgwhenvgcerebralvgbloodvgflowvgisvgreducedvg
byvganvgelevatedvgICP.
vgC.Dysphoriavgfromvgopioidsvgcontributesvgtovgalteredvglevelsvgofvgconsciousnessvgwithvga
nvgelevatedvgICP.
D.Opioidsvgsuppressvgrespirations,vgwhichvgincreasesvgPco2vgandvgcontributesvgtovganvgel
evatedvgICP.vg-vganswer--D
Thevggreatestvgriskvgassociatedvgwithvgopioidsvgsuchvgasvgmorphinevg(D)vgisvgrespiratoryvg
depressionvgthatvgcausesvganvgincreasevginvgPco2,vgwhichvgincreasesvgICPvgandvgmasksvg
thevgearlyvgsignsvgofvgintracranialvgbleedingvginvgheadvginjury.vg(A,vgB,vgandvgC)vgdovgnotvgsu
pportvgthevgrisksvgassociatedvgwithvgopioidvgusevginvgavgclientvgwithvgincreasedvgICP.
Thevgchargevgnursevgofvgavgmedicalvgsurgicalvgunitvgisvgalertedvgtovganvgimpendingvgdisaste
rvgrequiringvgimplementationvgofvgthevghospital'svgdisastervgplan.vgSpecificvgfactsvgaboutvgt
hevgnaturevgofvgthisvgdisastervgarevgnotvgyetvgknown.vgWhichvginstructionvgshouldvgthevgcha
rgevgnursevggivevgtovgthevgothervgstaffvgmembersvgatvgthisvgtime?
A.Preparevgtovgevacuatevgthevgunit,vgstartingvgwithvgthevgbedriddenvgclients.
vgB.UAPsvgshouldvgreportvgtovgthevgemergencyvgcentervgtovghandlevgtransports.
vgC.ThevglicensedvgstaffvgshouldvgbeginvgcountingvgwheelchairsvgandvgIVvgpolesvgonvgthevg
unit.
vgD.Continuevgwithvgcurrentvgassignments vguntilvgmorevginstructionsvgarevgreceived.vg-
vganswer--D
Whenvgfacedvgwithvganvgimpendingvgdisaster,vghospitalvgpersonnelvgmayvgbevgalertedvgbut
vgshouldvgcontinuevgwithvgcurrentvgclientvgcarevgassignments vguntilvgfurthervginstructionsvg
arevgreceivedvg(D).vgEvacuationvgisvgtypicallyvgavgresponsevgofvglastvgresortvgthatvgbeginsvg
withvgclientsvgwhovgarevgmostvgablevgtovgambulatevg(A).vg(B)vgisvgprematurevgandvgisvglikelyv
gtovgincreasevgthevgchaosvgifvgincomingvgcasualtiesvgarevganticipated.vg(C)vgisvgpoorvgutiliza
tionvgofvgpersonnel.
ThevgnursevgassessesvgavgclientvgwhilevgthevgUAPvgmeasuresvgthevgclient'svgvitalvgsigns.vg
Thevgclient'svgvitalvgsignsvgchangevgsuddenly,vgandvgthevgnursevgdeterminesvgthatvgthevgcli
ent'svgconditionvgisvgworsening.vgThevgnursevgisvgunsurevgofvgthevgclient'svgresuscitativevgst
atusvgandvgneedsvgtovgcheckvgthevgclient'svgmedicalvgrecordvgforvganyvgadvancedvgdirectiv
es.vgWhichvgactionvgshouldvgthevgnursevgimplement?
A.AskvgthevgUAPvgtovgcheckvgforvgthevgadvancedvgdirectivevgwhilevgthevgnursevgcompletesv
gthevgassessment.
B.AssignvgthevgUAPvgtovgcompletevgthevgassessmentvgwhilevgthevgnursevgchecksvgforvgthev
gadvancedvgdirective.
C.Checkvgthevgmedicalvgrecordvgforvgthevgadvancedvgdirectivevgandvgthenvgcompletevgthevg
clientvgassessment.
vgD.Callvgforvgthevgchargevgnursevgtovgcheckvgthevgadvancedvgdirectivevgwhilevgcontinuingvg
tovgassessvgthevgclient.vg-vganswer--D
, Becausevgthevgclient'svgconditionvgisvgworsening,vgthevgnursevgshouldvgremainvgwithvgthevg
clientvgandvgcontinuevgthevgassessmentvgwhilevgcallingvgforvghelpvgfromvgthevgchargevgnurs
evgtovgdeterminevgthevgclient'svgresuscitativevgstatusvg(D).vg(AvgandvgB)vgarevgtasksvgthatvgm
ustvgbevgcompletedvgbyvgavgnursevgandvgcannotvgbevgdelegatedvgtovgthevgUAP.vg(C)vgisvgcon
traindicated.
Thevgnursevgisvgpreparingvgavgclientvgforvgsurgeryvgscheduledvginvg2vghours.vgAvgUAPvgisvgh
elpingvgthevgnurse.vgWhichvgtaskvgisvgimportantvgforvgthevgnursevgtovgperform,vgrathervgthan
vgthevgUAP?
A.Removevgthevgclient'svgnailvgpolishvgandvgdentures.
vgB.Assistvgthevgclientvgtovgthevgrestroomvgtovgvoid.
vgC.Obtainvgthevgclient'svgheightvgandvgweight.
vgD.Offervgthevgclientvgemotionalvgsupport.vg-vganswer--D
Byvgusingvgtherapeuticvgtechniquesvgtovgoffervgsupportvg(D),vgthevgnursevgcanvgdeterminevg
anyvgclientvgconcernsvgthatvgneedvgtovgbevgaddressed.vg(A,vgB,vgandvgC)vgarevgallvgactionsvgt
hatvgcanvgbevgperformedvgbyvgthevgUAPvgundervgthevgsupervisionvgofvgthevgnurse.
Untilvgthevgcensusvgonvgthevgobstetricsvg(OB)vgunitvgincreases,vganvgunlicensedvgassistivev
gpersonnelvg(UAP)vgwhovgusuallyvgworksvginvglaborvgandvgdeliveryvgandvgthevgnewbornvgnu
rseryvgisvgassignedvgtovgworkvgonvgthevgpostoperativevgunit.vgWhichvgclientvgwouldvgbevgbe
stvgforvgthevgchargevgnursevgtovgassignvgtovgthisvgUAP?
vgA.Anvgadolescentvgwhovgwasvgreadmittedvgtovgthevghospitalvgbecausevgofvgavgpostoperati
vevginfection
vgB.Avgwomanvgwithvgavgnewvgcolostomyvgwhovgrequiresvgdischargevgteaching
vgC.Avgwomanvgwhovghadvgavghipvgreplacementvgandvgmayvgbevgtransferredvgtovgthevghome
vgcarevgunit
vgD.Avgmanvgwhovghadvgavgcholecystectomyvgandvgcurrentlyvghasvgavgnasogastricvgtubevgs
etvgtovgintermittentvgsuctionvg-vganswer--C
Thevgchargevgnursevgwillvgbevgresponsiblevgforvgprovidingvgavgreportvgtovgthevghomevgcarevg
unitvgifvgthevgtransfervgoccursvg(A).vgThevgclientvgisvginfectedvgandvganvgemployeevgwhovgwo
rksvgonvganvgOBvgunitvgshouldvgbevgassignedvgtovgcleanvgcasesvginvgcasevgthevgemployeevgi
svgrequiredvgtovgreturnvgtovgthevgOBvgunitvg(B).vgThisvgrequiresvgthevgskillsvgofvgavgregisteredv
gnursevg(RN)vgtovgdovgdischargevgteachingvgandvgprovidevgemotionalvgsupportvg(D).vgThisvg
mayvgrequirevgskillsvgbeyondvgthevglevelvgofvgthisvgUAP.
Avgmalevgclientvgisvgadmittedvgforvgobservationvgaftervgbeingvghitvgonvgthevgheadvgwithvgavgb
aseballvgbat.vgSixvghoursvgaftervgadmission,vgthevgclientvgattemptsvgtovgcrawlvgoutvgofvgbedvg
andvgasksvgthevgnursevgwhyvgtherevgarevgsovgmanyvgbugsvginvghisvgbed.vgHisvgvitalvgsignsvga
revgstable,vgandvgthevgpulsevgoximetervgreadingvgisvg98%vgonvgroomvgair.vgWhichvgintervent
ionvgshouldvgthevgnursevgperformvgfirst?
A.Administervgoxygenvgpervgnasalvgcannulavgatvg2vgL/min.
B.Planvgtovgcheckvghisvgvitalvgsignsvgagainvginvg30vgminutes.
C.Notifyvgthevghealthvgcarevgprovidervgofvgthevgchangevginvgmentalvgstatus.
D.Askvgthevgclientvgwhyvghevgthinksvgtherevgarevgbugsvginvgthevgbed.vg-vganswer--C
Onevgofvgthevgearliestvgsignsvgofvgincreasedvgintracranialvgpressurevg(ICP)vgisvgavgchangevg
invgmentalvgstatusvg(C).vgItvgisvgimportantvgtovgactvgearlyvgandvgquicklyvgwhenvgsymptomsvgo
fvgincreasedvgICPvgoccur.vgBecausevghisvgoxygenvgsaturationvgisvgnormal,vgthevgadministr
