HESI RN EXIT EXAM 2022/2023 1. In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? - -C) Security --HESI RN EXIT EXAM 2022/2023 1. In planning care for a 6 month-old infant, what must the nurs

HESI RN EXIT EXAM 2022/2023 1. In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? - -C) Security --HESI RN EXIT EXAM 2022/2023 1. In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? - -C) Security --2. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? - -B) "Would you please clarify what you have written so I am sure I am reading it correctly?" --2. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? - -B) "Would you please clarify what you have written so I am sure I am reading it correctly?" --3. What is the most important consideration when teaching parents how to reduce risks in the home? - -D) Age of children in the home --3. What is the most important consideration when teaching parents how to reduce risks in the home? - -D) Age of children in the home --4. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should - -C) Administer the prescribed analgesia --4. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should - -C) Administer the prescribed analgesia --5. While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention? - -A) Respiratory rate of 42 --5. While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention? - -A) Respiratory rate of 42 --6. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings? - -A) Lethargy --6. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings? - -A) Lethargy --7. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? - -B) "The seizure may or may not mean your child has epilepsy." --7. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? - -B) "The seizure may or may not mean your child has epilepsy." --8. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies? - -A) Risk for injury --8. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies? - -A) Risk for injury --9. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? - -B) Pale mucosa of the eyelids and lips --9. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? - -B) Pale mucosa of the eyelids and lips --10. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is - -D) Pupil responses --10. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is - -D) Pupil responses --11. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? - -D) A preschooler with intermittent episodes of alertness --11. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? - -D) A preschooler with intermittent episodes of alertness --12. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be - -D) Pale, thin arms and legs, uninterested in surroundings --12. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be - -D) Pale, thin arms and legs, uninterested in surroundings --13. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? - -D) Hair loss --13. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? - -D) Hair loss --14. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to - -B) Administer acetaminophen as ordered as this is normal at this time --14. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to - -B) Administer acetaminophen as ordered as this is normal at this time --15. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be - -B) Assess for dyspnea or stridor --15. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be - -B) Assess for dyspnea or stridor --16. Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? - -D) I went to the bathroom and my urine looked very red and it didn't hurt when I went. --16. Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? - -D) I went to the bathroom and my urine looked very red and it didn't hurt when I went. --17. Which of these parents' comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? - -C) Mild vomiting that progressed to vomiting shooting across the room. --17. Which of these parents' comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? - -C) Mild vomiting that progressed to vomiting shooting across the room. --18. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings? - -B) Tissue hypoxia --18. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings? - -B) Tissue hypoxia --19. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet - -A) High in carbohydrates and proteins --19. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet - -A) High in carbohydrates and proteins --20. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant? - -C) Tripled the birth weight --20. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant? - -C) Tripled the birth weight --21. A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to - -B) Ask the client what foods are acceptable or bad --21. A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to - -B) Ask the client what foods are acceptable or bad --22. 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? - -B) Imitation of sounds --22. 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? - -B) Imitation of sounds --23. The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended? - -B) Withdrawal --23. The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended? - -B) Withdrawal --24. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner's injuries by - -B) Minimizing the episode and underestimating the victim's injuries --24. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner's injuries by - -B) Minimizing the episode and underestimating the victim's injuries --26. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal - -A) S3 ventricular gallop --26. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal - -A) S3 ventricular gallop --27. Which of these observations made by the nurse during an excretory urogram indicate a complicaton? - -B) The client's entire body turns a bright red color --27. Which of these observations made by the nurse during an excretory urogram indicate a complicaton? - -B) The client's entire body turns a bright red color --28. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? - -B) "The tube will remove excess air from your chest." --28. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? - -B) "The tube will remove excess air from your chest." --29. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? - -D) Serum potassium 6 mEq/L --29. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? - -D) Serum potassium 6 mEq/L --30. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? - -C) Dyspnea --30. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? - -C) Dyspnea --31. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? - -C) Pulse oximetry of 88 --31. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? - -C) Pulse oximetry of 88 --32. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? - -D) Restlessness --32. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? - -D) Restlessness --33. During the evaluation phase for a client, the nurse should focus on - -B) The client's status, progress toward goal achievement, and ongoing re-evaluation --33. During the evaluation phase for a client, the nurse should focus on - -B) The client's status, progress toward goal achievement, and ongoing re-evaluation --34. The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should - -C) Compile a history of behavior patterns and developmental accomplishments --34. The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should - -C) Compile a history of behavior patterns and developmental accomplishments --35. Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care? - -A) Measure head circumference --35. Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care? - -A) Measure head circumference --36. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values? - -C) Bilirubin --36. A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values? - -C) Bilirubin --37. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct? - -D) Should be limited to 3-4 cups of milk daily --37. The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct? - -D) Should be limited to 3-4 cups of milk daily --38. The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client's behavior most likely indicates - -C) Flight of ideas --38. The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client's behavior most likely indicates - -C) Flight of ideas --39. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age? - -C) Riding a tricycle --39. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age? - -C) Riding a tricycle --40. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is - -D) Moist saline dressing --40. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is - -D) Moist saline dressing --41. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!" What would be the most appropriate next action? - -A) Leave the room and return five minutes later and give the medicine --41. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!" What would be the most appropriate next action? - -A) Leave the room and return five minutes later and give the medicine --42. 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? - -C) "If I drink, my baby may be harmed before I know I am pregnant." --42. 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? - -C) "If I drink, my baby may be harmed before I know I am pregnant." --43. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? - -C) Loss of pulse in the extremity --43. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? - -C) Loss of pulse in the extremity --44. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? - -C) Assist him to stand by the side of the bed to void --44. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? - -C) Assist him to stand by the side of the bed to void --45. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? - -B) Perform a quick assessment of the client's condition --45. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? - -B) Perform a quick assessment of the client's condition --46. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? - -B) "I am allergic to shrimp." --46. The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? - -B) "I am allergic to shrimp." --47. The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? - -A) Hold the tube feeding and notify the provider --47. The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? - -A) Hold the tube feeding and notify the provider --48. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must - -A) Apply suction for no more than 10 seconds --48. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must - -A) Apply suction for no more than 10 seconds --49. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to - -A) Administer the medication in 2 separate injections B) Give the medication in the dorsal gluteal site C) Call to get a smaller volume ordered D) Check with pharmacy for a liquid form of the medication skip --49. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to - -A) Administer the medication in 2 separate injections B) Give the medication in the dorsal gluteal site C) Call to get a smaller volume ordered D) Check with pharmacy for a liquid form of the medication skip --50. The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to - -A) Enhance absorption of the medication B) Ensure that the entire dose of medication is given C) Provide more even distribution of the drug D) Prevent the drug from tissue irritation Skip --50. The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to - -A) Enhance absorption of the medication B) Ensure that the entire dose of medication is given C) Provide more even distribution of the drug D) Prevent the drug from tissue irritation Skip --51. 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? - -A) Diaphoresis with decreased urinary output B) Increased heart rate with increase respirations C) Improved respiratory status and increased urinary output D) Decreased chest pain and decreased blood pressure --51. 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? - -A) Diaphoresis with decreased urinary output B) Increased heart rate with increase respirations C) Improved respiratory status and increased urinary output D) Decreased chest pain and decreased blood pressure --52. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? - -A) "As you urinate more, you will need less medication to control fluid." B) "You will have to take this medication for about a year." C) "The medication must be continued so the fluid problem is controlled." D) "Please talk to your health care provider about medications and treatments." --52. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? - -A) "As you urinate more, you will need less medication to control fluid." B) "You will have to take this medication for about a year." C) "The medication must be continued so the fluid problem is controlled." D) "Please talk to your health care provider about medications and treatments." --53. A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? - -A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dsypnea, nasal congestion --53. A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? - -A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dsypnea, nasal congestion --54. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? - -A. Cleanse the foot with soap and water and apply an antibiotic ointment B. Provide teaching about the need for a tetanus booster within the next 72 hours. C. have the mother check the child's temperature q4h for the next 24 hours D. transfer the child to the emergency department to receive a gamma globulin injection --54. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? - -A. Cleanse the foot with soap and water and apply an antibiotic ointment B. Provide teaching about the need for a tetanus booster within the next 72 hours. C. have the mother check the child's temperature q4h for the next 24 hours D. transfer the child to the emergency department to receive a gamma globulin injection --55. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences - -A. Bradycardia and constipation B. Lethargy and lack of appetite C. Muscle cramping and dry, flushed skin D. Palpitations and shortness of breath --55. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences - -A. Bradycardia and constipation B. Lethargy and lack of appetite C. Muscle cramping and dry, flushed skin D. Palpitations and shortness of breath --Obtain a list of medications taken for cardiac history 57. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) - - --Obtain a list of medications taken for cardiac history 57. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) - - --A. Fluid shifts from intravascular to interstitial area due to decreased serum protein B. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen C. Increased circulating aldosterone levels that increase sodium and water retention 58. The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) - - --A. Fluid shifts from intravascular to interstitial area due to decreased serum protein B. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen C. Increased circulating aldosterone levels that increase sodium and water retention 58. The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) - - --Murmur 59. 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? - -A) Transparent dressing B) Dry sterile dressing with antibiotic ointment C) Wet to dry dressing D) Occlusive moist dressing --Murmur 59. 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? - -A) Transparent dressing B) Dry sterile dressing with antibiotic ointment C) Wet to dry dressing D) Occlusive moist dressing --60. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? - -A) Cartoon stickers B) Large wooden puzzle C) Blunt scissors and paper D) Beach ball --60. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? - -A) Cartoon stickers B) Large wooden puzzle C) Blunt scissors and paper D) Beach ball --61. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the - -A) Yang, the positive force that represents light, warmth, and fullness B) Yin, the negative force that represents darkness, cold, and emptiness C) Use of improper hot foods, herbs and plants D) A failure to keep life in balance with nature and others --61. A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the - -A) Yang, the positive force that represents light, warmth, and fullness B) Yin, the negative force that represents darkness, cold, and emptiness C) Use of improper hot foods, herbs and plants D) A failure to keep life in balance with nature and others --62. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response? - -A) "There is a probability of life-long complications." B) "Cystic fibrosis results in nutritional concerns that can be dealt with." C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." D) "You will work with a team of experts and also have access to a support group that the family can attend." --62. A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response? - -A) "There is a probability of life-long complications." B) "Cystic fibrosis results in nutritional concerns that can be dealt with." C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." D) "You will work with a team of experts and also have access to a support group that the family can attend." --63. Which type of accidental poisoning would the nurse expect to occur in children under age 6? - -A) Oral ingestion B) Topical contact C) Inhalation D) Eye splashes --63. Which type of accidental poisoning would the nurse expect to occur in children under age 6? - -A) Oral ingestion B) Topical contact C) Inhalation D) Eye splashes --64. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client? - -A) Reading B) Checkers C) Cards D) Ping-pong --64. A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client? - -A) Reading B) Checkers C) Cards D) Ping-pong --65. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? - -A) Widening pulse pressure B) Pleural friction rub C) Distended neck veins D) Bradycardia --65. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? - -A) Widening pulse pressure B) Pleural friction rub C) Distended neck veins D) Bradycardia --66. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? - -A) Assess for generalized edema B) Monitor for increased urinary output C) Encourage rest during hyperactive periods D) Note patterns of increased blood pressure --66. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? - -A) Assess for generalized edema B) Monitor for increased urinary output C) Encourage rest during hyperactive periods D) Note patterns of increased blood pressure --67. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? - -A) Schedule the therapy thirty minutes after meals B) Teach the child not to cough during the treatment C) Confine the percussion to the rib cage area D) Place the child in a prone position for the therapy --67. The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? - -A) Schedule the therapy thirty minutes after meals B) Teach the child not to cough during the treatment C) Confine the percussion to the rib cage area D) Place the child in a prone position for the therapy --68. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? - -A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs --68. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? - -A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs --69. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? - -A) Three apricots B) Medium banana C) Naval orange D) Baked potato --69. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? - -A) Three apricots B) Medium banana C) Naval orange D) Baked potato --70. 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? - -A) Add a thickening agent to the fluids B) Check the client's gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids --70. 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? - -A) Add a thickening agent to the fluids B) Check the client's gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids --71. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? - -A) Place client in the wheelchair for four hours each day B) Pad the bony prominence C) Reposition every two hours D) Massage reddened bony prominence --71. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? - -A) Place client in the wheelchair for four hours each day B) Pad the bony prominence C) Reposition every two hours D) Massage reddened bony prominence --72. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? - -A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic client --72. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? - -A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic client --73. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? - -A) Obtain a complete blood count B) Obtain a health and dietary history C) Refer to a provider for a physical examination D) Measure height and weight --73. Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? - -A) Obtain a complete blood count B) Obtain a health and dietary history C) Refer to a provider for a physical examination D) Measure height and weight --74. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is - -A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents --74. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is - -A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents --75. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client? - -A) Allow the client to melt ice chips in the mouth B) Provide mints to freshen the breath C) Perform frequent oral care with a tooth sponge D) Swab the mouth with glycerin swabs --75. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client? - -A) Allow the client to melt ice chips in the mouth B) Provide mints to freshen the breath C) Perform frequent oral care with a tooth sponge D) Swab the mouth with glycerin swabs --76. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to - -A) Exercise doing weight bearing activities B) Exercise to reduce weight C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones --76. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to - -A) Exercise doing weight bearing activities B) Exercise to reduce weight C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones --77. The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? - -A) Cheese sandwich with a glass of 2% milk B) Sliced turkey sandwich and canned pineapple C) Cheeseburger and baked potato D) Mushroom pizza and ice cream --77. The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? - -A) Cheese sandwich with a glass of 2% milk B) Sliced turkey sandwich and canned pineapple C) Cheeseburger and baked potato D) Mushroom pizza and ice cream --78. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? - -A) All 4 side rails up, wheels locked, bed closest to door B) Lower side rails up, bed facing doorway C) Knees bent, head slightly elevated, bed in lowest position D) Bed in lowest position, wheels locked, place bed against wall --78. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? - -A) All 4 side rails up, wheels locked, bed closest to door B) Lower side rails up, bed facing doorway C) Knees bent, head slightly elevated, bed in lowest position D) Bed in lowest position, wheels locked, place bed against wall --79. The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group? - -A) Bulimia B) Anorexia C) Obesity D) Malnutrition --79. The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group? - -A) Bulimia B) Anorexia C) Obesity D) Malnutrition --80. 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 - -A) Invite the client to join the exercise group B) Tell the client you will call someone to come for her C) Give the client simple information about what she will be doing D) Firmly direct the client to her assigned group activity --80. 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 - -A) Invite the client to join the exercise group B) Tell the client you will call someone to come for her C) Give the client simple information about what she will be doing D) Firmly direct the client to her assigned group activity --81. A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse? - -A) "The violence is temporarily caused by unusual circumstances, don't stop hoping for a change." B) "Perhaps, if you understood the need to abuse, you could stop the violence." C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?" D) "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do." --81. A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse? - -A) "The violence is temporarily caused by unusual circumstances, don't stop hoping for a change." B) "Perhaps, if you understood the need to abuse, you could stop the violence." C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?" D) "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do." --82. A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation? - -A) Degeneration of the alveoli B) Chronic broncho constriction of the large airways C) Lung remodeling and permanent changes in lung function D) Frequent pneumonia --82. A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation? - -A) Degeneration of the alveoli B) Chronic broncho constriction of the large airways C) Lung remodeling and permanent changes in lung function D) Frequent pneumonia --83. 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? - -A) Change the baby to whole milk B) Add chocolate syrup to the bottle C) Continue with the present formula D) Offer fruit juice frequently --83. 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? - -A) Change the baby to whole milk B) Add chocolate syrup to the bottle C) Continue with the present formula D) Offer fruit juice frequently --84. Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice? - -A) When a family member offers information about their loved one B) When the client threatens self-harm and harm to others C) When the health care provider decides the family has a right to know the client's diagnosis D) When a visitor insists that the visitor has been given permission by the client --84. Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice? - -A) When a family member offers information about their loved one B) When the client threatens self-harm and harm to others C) When the health care provider decides the family has a right to know the client's diagnosis D) When a visitor insists that the visitor has been given permission by the client --85. The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care? - -A) Monitor for hyperkalemia B) Place in protective isolation C) Precautions with position changes D) Administer diuretics as ordered --85. The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care? - -A) Monitor for hyperkalemia B) Place in protective isolation C) Precautions with position changes D) Administer diuretics as ordered --86. The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment? - -A) Activity intolerance caused by fatigue related to chronic tissue hypoxia B) Impaired mobility related to chronic obstructive pulmonary disease C) Self-care deficit caused by fatigue related to dyspnea D) Ineffective airway clearance related to increased bronchial secretions --86. The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment? - -A) Activity intolerance caused by fatigue related to chronic tissue hypoxia B) Impaired mobility related to chronic obstructive pulmonary disease C) Self-care deficit caused by fatigue related to dyspnea D) Ineffective airway clearance related to increased bronchial secretions --87. The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure? - -A) Standing and sitting B) In both arms C) After exercising D) Supine position --87. The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure? - -A) Standing and sitting B) In both arms C) After exercising D) Supine position --88. The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group? - -A) Aerobic exercise classes B) Transportation for shopping trips C) Reminiscence groups D) Regularly scheduled social activities --88. The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group? - -A) Aerobic exercise classes B) Transportation for shopping trips C) Reminiscence groups D) Regularly scheduled social activities --89. Post-procedure nursing interventions for electroconvulsive therapy include - -A) Applying hard restraints if seizure occurs B) Expecting client to sleep for 4 to 6 hours C) Remaining with client until oriented D) Expecting long-term memory loss --89. Post-procedure nursing interventions for electroconvulsive therapy include - -A) Applying hard restraints if seizure occurs B) Expecting client to sleep for 4 to 6 hours C) Remaining with client until oriented D) Expecting long-term memory loss --90. The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding? - -A) Stand on 1 foot B) Catch a ball C) Skip on alternate feet D) Ride a bicycle --90. The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding? - -A) Stand on 1 foot B) Catch a ball C) Skip on alternate feet D) Ride a bicycle --. 91. 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 - -A) "Although the results are here, your doctor will explain them later." B) "Your child has less red blood cells that carry oxygen." C) "The blood cells that carry nutrients to the cells are too large." D) "There are not enough blood cells in your child's circulation." --. 91. 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 - -A) "Although the results are here, your doctor will explain them later." B) "Your child has less red blood cells that carry oxygen." C) "The blood cells that carry nutrients to the cells are too large." D) "There are not enough blood cells in your child's circulation." --92. In a child with suspected coarctation of the aorta, the nurse would expect to find - -A) Strong pedal pulses B) Diminishing carotid pulses C) Normal femoral pulses D) Bounding pulses in the arms --92. In a child with suspected coarctation of the aorta, the nurse would expect to find - -A) Strong pedal pulses B) Diminishing carotid pulses C) Normal femoral pulses D) Bounding pulses in the arms --93. At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates - -A) Feelings of increasing anxiety related to paranoia B) Social isolation related to altered thought processes C) Sensory perceptual alteration related to withdrawal from environment D) Impaired verbal communication related to impaired judgment --93. At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates - -A) Feelings of increasing anxiety related to paranoia B) Social isolation related to altered thought processes C) Sensory perceptual alteration related to withdrawal from environment D) Impaired verbal communication related to impaired judgment --94. A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0- to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to - -A) Ask the client about the refusal of certain pain medications B) Talk with the client's family about the situation C) Report the situation to the health care provider D) Document the situation in the notes --94. A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0- to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to - -A) Ask the client about the refusal of certain pain medications B) Talk with the client's family about the situation C) Report the situation to the health care provider D) Document the situation in the notes --95. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? - -A) Presence of blood in stools B) Oozing liquid stool C) Continuous rumbling flatulence D) Absence of bowel movements --95. What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? - -A) Presence of blood in stools B) Oozing liquid stool C) Continuous rumbling flatulence D) Absence of bowel movements --96. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to - -A) Have the client identify coping methods B) Get the description of the location and intensity of the pain C) Accept the client's report of pain D) Determine the client's status of pain --96. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to - -A) Have the client identify coping methods B) Get the description of the location and intensity of the pain C) Accept the client's report of pain D) Determine the client's status of pain --97. An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be - -A) Assess the severity and location of the pain B) Obtain an order for an analgesic C) Reassure him that this is not unusual for his age D) Encourage him to increase his activity --97. An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be - -A) Assess the severity and location of the pain B) Obtain an order for an analgesic C) Reassure him that this is not unusual for his age D) Encourage him to increase his activity --98. A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: - -A) Visitors must wear a mask and a gown B) There are no special requirements for visitors of clients on contact precautions C) Visitors should wash their hands before and after touching the client D) Visitors --98. A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: - -A) Visitors must wear a mask and a gown B) There are no special requirements for visitors of clients on contact precautions C) Visitors should wash their hands before and after touching the client D) Visitors --99. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? - -A) Institute seizure precautions B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h --99. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? - -A) Institute seizure precautions B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h --100. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? - -A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia --100. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? - -A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia --100. A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? - -A) An infant who has been identified to have botulism B) A toddler who ate a number of ibuprofen tablets C) A preschooler who swallowed powdered plant food D) A school aged child who took a handful of vitamins --100. A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? - -A) An infant who has been identified to have botulism B) A toddler who ate a number of ibuprofen tablets C) A preschooler who swallowed powdered plant food D) A school aged child who took a handful of vitamins --101. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? - -A) Apply appropriate signs outside and inside the room B) Apply a mask with a shield if there is a risk of fluid splash C) Wear a gown to change soiled linens from incontinence D) Have gloves on while handling bedpans with feces --101. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? - -A) Apply appropriate signs outside and inside the room B) Apply a mask with a shield if there is a risk of fluid splash C) Wear a gown to change soiled linens from incontinence D) Have gloves on while handling bedpans with feces --102. Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? - -A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin --102. Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? - -A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin --103. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? - -A) Reverse B) Airborne C) Standard precautions D) Contact --103. A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? - -A) Reverse B) Airborne C) Standard precautions D) Contact --104. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? - -A) "The treatment requires reapplication in 8 to 10 days." B) "Bedding and clothing can be boiled or steamed." C) Children are not to share hats, scarves and combs. D) Nit combs are necessary to comb out nits. --104. The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? - -A) "The treatment requires reapplication in 8 to 10 days." B) "Bedding and clothing can be boiled or steamed." C) Children are not to share hats, scarves and combs. D) Nit combs are necessary to comb out nits. --105. During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? - -A) Wash hands thoroughly before and after client contact B) Wear gloves when in contact with body secretions C) Double glove when in contact with feces or vomitus D) Wear gloves when disposing of contaminated linens --105. During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? - -A) Wash hands thoroughly before and after client contact B) Wear gloves when in contact with body secretions C) Double glove when in contact with feces or vomitus D) Wear gloves when disposing of contaminated linens --106. A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes? - -A) Grilled chicken sandwich and skim milk B) Roast beef, mashed potatoes, and green beans C) Peanut butter sandwich, banana, and iced tea D) Barbecue beef, baked beans, and cole slaw --106. A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes? - -A) Grilled chicken sandwich and skim milk B) Roast beef, mashed potatoes, and green beans C) Peanut butter sandwich, banana, and iced tea D) Barbecue beef, baked beans, and cole slaw --107. After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, "My husband told me to get treatment or he would divorce me. I don't believe I really need treatment but I don't want my husband to leave me." Which response by the nurse would assist the client? - -A) "In early recovery, it's quite common to have mixed feelings, but unmotivated people can't get well." B) "In early recovery, it's quite common to have mixed feelings, but I didn't know you had been pressured to come." C) "In early recovery it's quite common to have mixed feelings, perhaps it would be best to seek treatment on an out client bases." D) "In early recovery, it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you." --107. After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, "My husband told me to get treatment or he would divorce me. I don't believe I really need treatment but I don't want my husband to leave me." Which response by the nurse would assist the client? - -A) "In early recovery, it's quite common to have mixed feelings, but unmotivated people can't get well." B) "In early recovery, it's quite common to have mixed feelings, but I didn't know you had been pressured to come." C) "In early recovery it