HESI RN CAT EXIT EXAM

HESI RN CAT EXAM EXIT 1- A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client’s condition? a. The client has increased intracranial pressure b. He has a good prognosis for recovery c. This client is conscious, but is not oriented to time and place d. He is in a coma, and has a very poor prognosis Correct D 2- At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond? a. Encourage the woman to explore her fears about breast cancer. b. Ask the woman if she also performs monthly breast self- exams. c. Commend the woman for adhering to the recommended cancer detection guidelines. d. Advise the woman that mammograms are only needed every two years at her age. Correct B 3- Which assessment finding should indicate to the nurse that a client with arterial hypertension is experiencing a cardiac complication? a. Complaints of an occipital headache b. A palpable dorsal is pedis pulse bilaterally c. Complaints of shortness of breath on exertion d. A blood pressure of 160/90 Correct C 4- A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a “cottage cheese” appearance. Which prescription should the nurse implement first? a. Cleanse perineum with warm soapy water 3 times per day b. Instill the first dose of nystatin (Mycostatin) vaginally per applicator c. Perform glucose measurement using a capillary blood sample d. Obtain a blood specimen for sexually transmitted disease (STDs) Correct B 5- A client in acute renal failure has serum potassium of 7.5 mEq/L. Based on this finding, the nurse should anticipate implementing which action? a. Administer an IV of normal saline rapidly and NPH insulsubcutaneously. b. Administer a retention enema of Kayexalate c. Add 40 mEq of KCL (potassium chloride) to present IV solution. d. Administer a lidocaine bolus IV push. Correct B 6- A client who had an intraosseous (IO) cannula placed by the healthcare provider for an emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse takes first? a. Discontinue the IO infusion b. Administer an analgesic via the IO site c. Elevate the extremity with the IO site d. Notify the healthcare provider Correct A 7- The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to male room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit? a. A 45-year-old who has a chronic hepatitis B. b. A 35-year-old with lupus erythematous c. A 19-year-old who is diagnosed with rubella d. A 25-year-old with herpes lesions of the vulva Correct B 8- A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this client to do to maintain sustained maximal inspiration? a. Breathe into the spirometer using normal breath volumes b. Exhale forcefully into the tubing for 3 to 5 seconds c. Inspire deeply and slowly over 3 to 5 seconds d. Perform IS breathing exercises every 6 hours Correct C 9- The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic medication clozapine (Clozaril). Which statement should the nurse provide? a. You will be able to cope with your symptoms b. It will help you function better in the community c. The medication will help you think more clearly” d. It will improve your grooming and hygiene Correct C 10 – A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. What action should the nurse implement? a. Offer to obtain a new breakfast tray in an hour so the client can take the Zithromax b. Instruct the client to eat his breakfast and take the Zithromax two hours after eating c. Tell the client to skip that day’s dose and resume taking the Zithromax the next day d. Provide a PRN dose of an antacid to take with the Zithromax right after breakfast Correct B 11-What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis? a. Avoid douching b. Treat sexual partner (s) concurrently c. Avoid using moist washcloths when bathing d. Postpone becoming pregnant until the infection is treated Correct B 12- A primigravida at term comes to the prenatal clinic and tells the nurse that she is having contractions every 5 min. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client’s contractions every 5 minutes. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client’s contractions are 7 to 15 minutes apart, lasting 20 to 30 seconds, with mild intensity by palpation. What action should the nurse take? a. Tell the client to go directly to the hospital for admission to labor and delivery for active labor b. Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour c. Tell the client to check into the hospital within the next hour for evaluation of possible urinary tract infection Correct B 13- Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker? a. Wear long-sleeved clothing when outdoors b. Report the onset of sore throat c. Eat plenty of potassium-rich food d. Change the position slowly Correct D 14- Assessment finding of a 3-hour-old newborn include: axillary temperature of 97.7 F, heart rate of 140 beats/minute with a soft murmur, and irregular respiratory rate at 42 breaths/min. Based on these findings, what action should the nurse implement? a. Place a pulse oximeter on the heel b. Swaddle the infant in a warm blanket c. Record the findings on the flow sheet d. Check the vital signs in 15 minutes Correct C 15- A client admitted to the hospital for depression is escorted to a private room. Prior to leaving the room, what intervention is most important for the nurse to implement? a. Explain the programs guidelines b. Search all personal belongings c. Initiate psychosocial assessment d. Review the healthcare’s provider’s prescription Correct B 16- An experienced nurse tells the nurse-manager that working with a new graduate is impossible because the new graduate will not listen to suggestions. The new graduate comes to the nurse-manager describing the senior nurse’s attitude as challenging and offensive. What action is best for the nurse manager to take? a. Have both nurses meet separately with the staff mental health consultant b. Listen actively to both nurses and offer suggestions to solving dilemma c. Ask the senior nurse to examine mentoring strategies used with the new graduate d. Ask the nurses to meet with the nurse-manager to identify ways of working together Correct D 17- Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock? a. Risk for imbalance body temperature b. Excess fluid volume c. Fatigue d. Ineffective Tissue Perfusion Correct D 18- A client who had a cerebral vascular accident (CVA) Is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client’s current health status? a. Risk for impaired tissue integrity related to impaired physical mobility b. Impaired skin integrity related to altered circulation and pressure c. Ineffective tissue perfusion related to inability to move self in bed. d. Impaired physical mobility related to the left side paralysis Correct B 19- The nurse offers diet teaching to a female college student who was diagnosed with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet? a. Drink whole milk instead of skim milk to enhance the body’s production of amino acids b. Take vitamin K 10mg PO daily to enhance production of red blood cells c. Increase amounts of dark yellow vegetables such as carrots to fortify iron stores d. Combine several legumes and grains such as beans and rice to form complete proteins Correct D 20- The nurse is triaging clients from a train wreck. A client has multiple open wounds, a blood pressure of 90/56, and a pulse of 112 beats/minute. Which triage tag color should the nurse place on this client? a. Black b. Yellow c. Green d. Red Correct D 21- Which action should the nurse include in the plan of care a client who is receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)? a. Initiate cardiac telemetry monitoring b. Maintain continuously pulse oximetry c. Perform capillary glucose measurements d. Monitor serum creatinine levels Correct D 22- A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data? a. Bladder distention b. Serum albumin level c. Abdominal girth d. Breath sounds Correct D 23- A male adult client is transferred to a psychiatric facility following release from the hospital for treatment of a self-inflicted gunshot wound. In attempting to develop a therapeutic relationship with this client, which information is most important for the nurse to determine? a. The family’s reaction to this situation b. The nurse’s feeling about this client c. What losses the client recently experienced d. Why the client attempted to kill himself Correct B 24-Which client requires careful nursing assessment for signs and symptoms of hypomagnesaemia? a. A young adult client with intractable vomiting from food poisoning b. A client who developed hyperparathyroidism in late adolescence c. A middle-age male client in renal failure following an unsuccessful kidney transplant d. A female client who is overzealous with her intake of simple carbohydrates Correct C 25- While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement? a. Elevate the head of the client’s head b. Auscultate the client’s breath sound c. Measure the length of the apneic periods d. Suction the client’s oropharynx Correct C 26- The nurse is preparing to administer the 0800 dose of 20 units of Humulin R to an 8-year-old girl diagnosed with Type 1 diabetes. The mother comments that her daughter is a very picky eater and many times does not eat meals. Which intervention should the nurse implement first? a. Administer the 20 Units of Humulin R subcutaneously as prescribed b. Ask the girl if she will be eating her breakfast this morning c. Discuss changing the insulin prescription to Lispro with the healthcare provider d. Explain to the mother the importance of eating the schedule meals Correct B 27- The nurse working in an emergency center collects physical evidence 6 hours following a reported sexual assault. After placing the samples in sealed containers, which action is most important for the nurse to implement? a. Maintain possession of the evidence collection kit at all times until submitted to law enforcement b. Provide discharge instruction for prophylactic antibiotic, pregnancy, and HIV prevention medication c. Document the characteristics of the various sites of sample collection d. Assist the client with toileting, hygiene, and dressing with clean clothes. Correct A 28- The nurse is caring for a 10-year-old who is diagnosed with acute glomerulonephritis. Which outcome is the priority for this child? a. Activity tolerance as evidenced by performing appropriate age-level-activities b. No signs of skin breakdown as evidenced by intact skin and no redness c. Adequate nutritional status as evidenced by no weight gain or loss d. Fluid balance maintained as evidenced by a urine output of 1 to 2 ml/kg/hr Correct D 29- A 20-year-old male client is diagnosed with Ewing’s sarcoma following examination for a knee injury. Which instruction is most important for the nurse to provide the client? a. Take analgesics regularly to reduce the pain b. Notify the healthcare provider if the swelling worsens c. Avoid weight-bearing until the injury heals d. Seek treatment for the sarcoma immediately Correct D 30- The nurse in the newborn nursery admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finds helps to confirm this diagnosis? a. Pink lips and tongue with cyanotic hands and feet b. Respiration rate of 40 and heart rate of 144 c. Centralized cyanosis and tachycardia when crying d. Desquamation from areas of cracked, parchment-like skin Correct C 31- A postoperative client returns to the nursing unit following a ureter lithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client? a. Ineffective airway clearance b. Altered nutrition less than body requirements c. Fluid volume excess d. Activity intolerance Correct A 32- A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg/ml. what is the maximum dosage in mg that the nurse should administer to this client? (Enter numeric value only) Ans: 2 0.4 mg/dose = x mg/5 doses X= 2 mg 33- A male client admitted three days ago with respiratory failure is intubated and with 40% oxygen per facemask is initiated. Currently his temperature is 99 F, capillary refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful estuation? a. Exhibits adequate tissue perfusion b. Remains free of injury c. Remains free of infection d. Maintains effective breathing pattern Correct D 34- When the nurse enters the room to change the dressing of a male client with cancer, he asks, “Have you ever been with someone when they died?” What is the nurse’s best response to him? a. “Yes I have. Do you have some questions about dying?” b. “Several times. Now, let’s get your dressing changed” c. “A few times. It was peaceful and there was no pain” d. “Yes, but you’re doing great. Are you concerned about dying?” Correct A 35- A client with a C-6 spinal injury changes to a breathing pattern of shallow respirations and dyspnea twelve hours after the causative incident. The nurse should notify the healthcare provider and implement which intervention? a. Put the client in reverse Trendelenburg position b. Prepare for intubation with an endotracheal tube c. Administer a pain medication to the client d. Instruct the client on deep breathing exercises Correct B 36- When caring for a laboring client whose contractions are occurring every 2 to 3 min, the nurse should document that the pump is infusing how many ml/hr? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record. Ans: 42 37- When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll o the bottom right corner of each tab to view all information contained in the client’s medical record. ANS 5 38- The nurse in a community health clinic is interviewing a female client who has three children. The client tells the nurse that she has a new man in her life, with whom she is having a sexual relationship, and that they both smoke cigarettes. Which information is most important for the nurse to provide this client? a. Oral contraceptives should be started to prevent an unwanted pregnancy b. Children have more upper respiratory infections if exposed to smoke at home c. Cigarette smoking increases the risk for peptic ulcers and emphysema d. A diaphragm and condom provide effective contraception when used together Correct D 39- An adult male is admitted to the psychiatric unit from the emergency department because he is in the manic disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been “trying to start a new business” and is “too busy to eat.” He is alert and oriented to time, place and person, but not situation. Which nursing diagnosis has the greatest priority? a. Self-care deficit b. Disturbed sleep pattern c. Disturbed thought processes d. Imbalanced nutrition Correct D 40- A 9 year-old received a short arm cast for a right radius. To relieve itching under the child’s cast, which instructions should the nurse provide to the parents? a. Blow cool air from a hair dryer under the cast b. Twist the cast back and forth c. Shake powder into the cast d. Push a pencil under the cast edge Correct A 41- A client in the oliguric phase of acute renal failure (ARF) has a 24-hour urine output of 400 ml. The nurse should allow this client to have how much oral intake during the next 24 hours? a. Encourage oral fluids as tolerated b. Decrease oral intake to 200 ml c. Allow the client to have exactly 400 ml oral intake d. Limit oral intake to 900 to 1,000 ml Correct D 42- A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client’s wrists and asks what happened. She doesn’t respond. What should the nurse do next? a. Find supplies to put a dressing on the client’s wrist b. Take the client to a room for supervision by staff c. Call the healthcare provider to report the client’s behavior d. Go find a staff to stay in the room with the client Correct B 43- What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)? a. Bladder palpation b. Inspection of the mouth c. Blood glucose monitoring d. Auscultation of breath sounds Correct B 44- The nurse is assessing on the first postoperative day following thyroid surgery. Which laboratory value is most important for the nurse to monitor? a) Calcium b) Sodium c) Chloride d) Potassium Correct A 45- The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, “What do you think you’re doing?” How should the nurse respond? a.” I cannot give you this medication until you calm down” b. “This shot will help relieve the pain in your feet.” c. “Would you prefer to learn to administer your own shot?” d. “You will feel calmer and less jittery after this shot” Correct B 46- When administering an intramuscular injection containing 3 ml of a painful medication, which intervention should the nurse implement? a. Instill the medication quickly b. Insert the needle slowly c. Select a large, deep muscle mass d. Use a short small gauge needle Correct C 47- Several clients on a telemetry unit are schedule for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit? The client who is a. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus b. Ambulatory following coronary artery bypass graft surgery performed six days ago. c. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day d. Experiencing syncopal episodes resulting from the dehydration caused by severe diarrhea Correct A 48- The nurse preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify? a. Tachycardia, mental status change, and low urine output b. Warm skin, hypertension, and constricted pupils c. Bradycardia, hypotension, and respiratory acidosis d. Mottled skin, tachypnea and hyperactive bowel sounds Correct A 49- The nurse is making assignments for a new graduate from a practical nursing program that is orienting to the unit. Because the unit is particularly busy this day, there will be little time to provide supervision of this new employee. Which client is the best for the nurse to assign this newly graduate practical nurse? A client a. Whose discharge has been delayed because of a postoperative infection b. With poorly controlled type 2 diabetes who is sliding scale for insulin administration c. Newly admitted with a head injury who requires frequent assessments d. Who is receiving IV heparin that is regulated based on protocol Correct A 50- Nurses working in labor and delivery are demanding a change in policy because they believe they are required to float more often than nurses on other units. However, floating to labor and delivery is not reciprocated because other nurses are not competent to provide highly specialized obstetrical skills. What action is best for the nurse-manager to implement? a. Require the other nurses to cross-train for obstetrics b. Propose a method for self-staffing labor and delivery c. Remind nurses that floating is an administrative policy d. Encourage nurses to share their feelings with administration Correct B 51- Locate the optic disk. (Click the chosen location. To change, click on the new location.) 52- The nurse has explained safety precautions and infant care to a primigravida mother and observes the mother, as gives care to her newborn during the first two days of rooming-in. Which action indicates the mother understand the instruction? a. Aspirates the newborn’s nares using syringe b. Applies a dressing on the cord after the newborn’s bath c. Breastfeeds the infant every hour during the night d. Positions the infant supine in the crib to sleep Correct D 53- The nurse teaches the mother of a 6 year-old anemic boy to give iron supplements. Which statement indicates that the mother understands the proper administration of iron? a. “The iron tablets will be absorbed between meals, on an empty stomach” b. “I should give the iron tablets with his milk and cereal each morning” c. “Iron preparations can be taken with antibiotics if he develops an infection” d. “The iron tablets may cause him to sunburn more easily so he should wear sunscreen” Correct A 54- “Oxygen at liters/min per nasal cannula PRN difficult breathing” is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity? a. Avoiding the administration of oxygen at high levels for extended periods. b. Administering a sedative at bedtime to slow the client’s respiratory rate c. Removing the nasal cannula during the night to prevent oxygen buildup d. Running oxygen through a hydration source prior to administration Correct A 55- The healthcare provider prescribes amoxicillin (Amoxil) 1.5 grams PO daily, in equally divided doses to be administer every 8 hours. The medication is available in a bottle labeled, “Amoxicillin (Amoxil) suspension 200 mg/5 ml.” How many ml should the nurse administer every 8 hours? (Enter numeric value only. If rounding is required, round to the nearest tenth.) Ans: 12.5 56- A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every mouth. What action should the nurse implement in response to the client’s statements? a. Remind the client that is also important to schedule an annual mammogram b. Refer the client to a nurse practitioner for an in-depth review of the BSE procedure c. Encourage the client to perform BSE 2 to 3 days after menstrual period ends d. Instruct the client to continue with her regular monthly exams as she is doing Correct C 57- A 2-year-old boy has short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2  F and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated? a. Occult blood in the stool b. Abdominal distention c. Elevated urine specific gravity d. Hyperactive bowel sounds Correct C 57- One hour after delivery the nurse is unable to palpate the uterine fundus of a client and notes a large amount of lochia on the perineal pad. Which intervention should the nurse implement first? a. Empty the bladder using an indwelling urinary catheter b. Increase the rate off the IV containing oxytocin (Pitocin) c. Assess for shock by determining the blood pressure d. Perform gentle massage at the level of the umbilicus Correct D 58- A client with a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the unlicensed assistive personnel (UAP) who is completing morning care for this client? a. Maintain a quiet environment b. Ensure the linens are clean and dry c. Place an air deodorizer in the room d. Measure all emesis accurately Correct D 59- A child with Leukemia is admitted for chemotherapy, and the nursing diagnosis, “altered nutrition, less than body requirements related to anorexia, nausea, vomiting” is identified. Which intervention should the nurse include in this child plan of care? a. Allow the child to eat foods desired and tolerated b. Restrict foods brought from fast food restaurants c. Recommend eating the same foods as siblings eat at home d. Encourage a variety of large portions of food at every meal Correct A 60- The nurse is teaching a class on child care to new parents. Which instruction should be included about the prevention of rotavirus infection in infants who are starting to eat foods? a. Keep house pets away from the food preparation area b. Avoid feeding infants fresh fruits c. Use only lactose-free formulas d. Wash hands before any food preparation Correct D 61- The nurse believes that a client who frequently requests pain may have a substance abuse problem. Which intervention reflects the nurse’s value of client autonomy over veracity? a. Administer the prescribed analgesic when requested b. Enroll the client a substance abuse program c. Collaborate with the healthcare provider to provide a placebo d. Document the frequency of medication requests Correct A 62- An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action the nurse takes first? a. Prepare for immediate cesarean birth b. Turn off the oxytocin (Pitocin) infusion c. Notify the anesthesiologist that the epidural infusion needs to be disconnected d. Apply an internal fetal monitoring device and continue to monitor carefully Correct B 63- In preparing to administer a scheduled dose of intravenous furosemide (Lasix) to a client with heart failure, the nurse notes that the client’s B-Type Naturetic peptide (BNP) is elevated. What action should the nurse take? a. Measure the client’s oxygen saturation before taking further action b. Administer a PRN does of nitroglycerin (Nitrostat) c. Administer the dose of furosemide as scheduled d. Hold the dose of furosemide until contacting the healthcare provider Correct C 64- When obtaining a urine specimen from a female infant, which intervention should the nurse implement? a. Place the wet diaper in a biohazard specimen bag b. Obtain the urine sample using a straight sixe 4 French catheter c. Collect the urinary stream in mid-air when the infant cries d. Secure the pediatric urine collector bag to the perineum Correct D 65- A client is leaving the hospital against medical advice (AMA) and voluntarily signs the AMA form. Which nursing action is essential prior to the client leaving? a) Remove the client’s peripheral IV access b) Administer requested medication to pain relief c) Obtain the client’s neurological vital signs d) Provide the client with the hospital’s phone number Correct A 66- A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client? a. The depth of tissue destructions is minor b. Pain is interrupted due to nerve compression c. The full thickness burn has destroyed the nerves d. Second degree burns are not usually painful Correct C 67- The nurse observes a client in a wheelchair with a vest restraint in place. What nursing intervention is most important for the nurse to implement? a. Assess the need for continued restraint b. Check the client for urinary incontinence c. Determine skin integrity under the vest d. Perform range-of-motion exercises on extremities Correct A 68- A 14-year-old girl with asthma complains of feeling nervous and jittery after a respiratory therapy bronchodilator treatment. What explanation is best for the nurse to provide to this adolescent? a. Nervousness should disappear when hypoxia is relieved after several bronchodilator treatments b. Tremors result from the rapid dilation of the bronchioles and an increased heart rate c. A fast heart rate and jitteriness are side effects of the bronchodilator treatment containing albuterol d. Excessive coughing, which causes tachypnea and anxiety, result from the use of bronchodilators Correct C 69- A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select all that apply.) a. Increased heart rate b. Visual disturbances c. Presence if uremic frost d. Decreased mentation e. Blood glucose 400 mg/dl Correct A,B,D 70- The husband and adult children of a woman who abuses alcohol ask the nurse what approach to use when her drinking behavior disrupts family plans. Which response is best for the nurse to provide? a. “Destroy the hidden supplies of alcohol she has at home so she has to stay sober” b. “When she drinks, tell her how disruptive her behaviors are and the burden they inflict on the family” c. “Make her responsible for the consequences of her drinking behaviors” d. “Include her as a part of family activities whether she is drinking or sober” Correct C 71- A client whose finger stick glucose is 210 mg/dl is receiving a sliding scale dose of short-acting insulin before breakfast. In what sequence should the nurse prepare the dose of insulin? (Arrange from first on top to last on the bottom) 72- The nurse is preparing to administer an IM injection to a 6 month-old child. Which injection site is best for the nurse to use? a) Vastus lateralis b) Deltoid c) Ventrogluteal d) Dorsogluteal Correct A 73- The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement? a. Perform passive range of motion to the right leg b. Remove skeletal weights every shift to assess right leg c. Turn frequently from prone to supine positions d. Maintain skeletal pin sites and assess for signs of infection Correct D 74- A male client is admitted to the mental health unit because he experiences panic attacks when driving on the freeway. To attempt to desensitize this fear, what action should the nurse encourage the client to implement? a. Watch training videos of people driving in various environments b. Begin visualizing himself driving each route to the freeway c. Take antianxiety medication two hours before driving on freeways d. Get in the car with a support person and drive on a freeway during rush hour. Correct B 75- A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, “I wish this medicine would hurry up and dissolve this clot in my ling so that I can go home”. What response is best for the nurse to provide? a. “Heparin prevents future clot formation, but your risk of bleeding needs to be monitored closely” b. “You seem to be concerned about the length of time it takes for Heparin to dissolve this clot” c. “Let me contact your surgeon and find out Heparin IV therapy can be given to you at home” d. “Why are you so anxious to leave the hospital when you know you are not well enough yet?” Correct A 76- An angry client screams at the emergency department triage nurse, “I’ve been waiting here for two hour! You and the staff are incompetent” What is the best response for the nurse to make? a. “The emergency department is very busy at this time” b. “I’ll let you see the doctor next because you’ve waited so long” c. “I’m doing the best I can for the sickest clients first” d. “I understand you are frustrated with the wait time” Correct D 77- The UAP asks if it is necessary to continue to strain the urine of a client with kidney stones since several stones were obtained the previous day. What information should the nurse provide the UAP? a. UAPs do not have authority to question prescribed care b. It is important to continue straining all the client’s urine c. Measuring intake and output is more important than straining the urine d. Ensuring that the client is free from pain is a higher priority care Correct B 78- Which assessment finding is most indicative of deep vein thrombosis (DVT) in a client’s right leg? a. Dorsiflexes the right foot and left on command b. A 3 by 5cm ecchymosis area covering the right calf c. Right calf is 3 cm larger in circumference than the left d. Bilateral lower extremity has 3+ pitting edema Correct C 79-The nurse is caring for a laboring 22 year-old primigravida following administration of regional anesthesia. In planning care for this client, what nursing intervention has the highest priority? a. Raising the side rails and placing the call bell within reach b. Teaching the client how to push to decrease the length of the second stage of labor c. Timing and recording uterine contractions d. Positioning the client for proper distribution of anesthesia Correct A 80- The nurse is caring for a client with jaundice. Which serum laboratory value is likely to be elevated for this client? a. Amylase b. Creatinine c. Blood urea nitrogen d. Bilirubin Correct D 81- When evaluating the preoperative teaching of a client scheduled for arthroscopic anterior cruciate ligament repair, which statement by the client indicates that the teaching was effective? a. “I will use crutches to keep my weight off my knee” b. “ I will stay home until a wheelchair is delivered” c. “ I can use the trapeze bar and side rails on the bed to help me turn regularly” d. “ I can put my full weight on my foot starting the day after surgery” Correct A 82- When lactulose (Cephulac) 30 ml QID is prescribed for a male client with advances cirrhosis, he complains that it causes diarrhea. What action the nurse takes in response to the client’s statement? a. Explain that diarrhea is expected, but the drug reduces ammonia levels b. Document that the client is non-compliant with his treatment plan c. Tell the client to be concerned about more significant side effects of this drug d. Obtain a prescription for loperamide (Imodium) 4mg PO PRN diarrhea Correct A 83- The nurse is obtaining the medical histories of new clients at a communitybased primary care clinic. Which individual has the highest risk for experiencing elder abuse? a. A 69-year- old widowed female who lives alone and volunteers at a school b. A 95-year-old ambulatory male who resides in nursing home in a small town c. A 78-year-old female on a fixed income who lives with her relatives d. An 81-year-old male with diabetes who lives with his wife of 52 years Correct C 84- A 70-year-old client is admitted to the hospital after 24 hours of acute diarrhea. To determine fluid status, which initial data is most important for the nurse to obtain? a. Usual and current weight b. Color and amount of urine c. Number and frequency of stools d. Intake and output 24 hours prior to admission Correct A 85- A client with a BMI of 60.2 kg/m is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending multiple organ dysfunction syndrome (MODS). What should the nurse prepare to implement first? a. Mechanical ventilation b. Platelet transfusion c. Loop diuretic therapy d. Cyanocobalamin administration Correct A 86- Before administering an intramuscular injection, the nurse’s finger is stuck with the needle. Which action should the nurse take? a. Go to the emergency room to have blood drawn b. Prepare the medication using a new syringe c. Apply clean gloves before giving the medication d. Review the medical history in the client’s chart Correct B 87- The nurse notices that a client with diabetes mellitus type 1 has a fruity breath odor. What is the priority nursing action? a. Evaluate the client’s intake and output b. Measure the client’s capillary blood glucose c. Consult with the dietician about the client’s diet d. Apply a pulse oximeter to the client’s finger Correct B 88- After implementing a new fall prevention protocol on the nursing unit, which action by the nurse-manager best evaluates the protocol’s effectiveness? a. Compare the number of falls that occurred before and after protocol implementation b. Analyze data that reflects the unit’s costs incurred when implementing the new protocol c. Conduct a chart review on the unit to determine the number of clients at risk for falling d. Consult with the physical therapist to evaluate the benefits of the new fall protocol Correct A 89- A client receives a prescription for acetylcysteine (Mucomyst) 1.4 grams per nasogastric tube q4 hours. Acetylcysteine is available a 10% solution (10 grams/100ml). How many ml of the 10% solution should the nurse administer per dose? (Enter the numerical value only.) Ans: 14 90- A client who is diagnosed with amyotrophic lateral sclerosis (ALS) is having difficulty swallowing and articulating words. Which intervention is most important to include in this client’s plan of care? a. Encourage to speak slowly and articulate words b. Sit upright and flex chin forward while swallowing c. Position a communication board at the bedside d. Provide feeding utensils with large grip handles Correct B 91- When preparing the client for a thoracentesis, it is essential for the nurse to take which action? a. Encourage the client to cough during the procedure b. Ask the client to void prior to the procedure c. Have the client lie in the prone position d. Determine if chest x-rays have been completed Correct D 92- In deciding whether to join a nursing strike called after collective bargaining efforts have failed, which factors is most important for the nurse to consider? a. Nurse Practice Act of the State b. The role of the nurses as client advocate c. Standards of clinical nursing practice d. Personal value system Correct D 93- The nurse is preparing to teach the parents of a child who had surgical repair of a myelomeningocele how to change an occlusive dressing on the child’s back. Which statement by the parents indicates that they understand this procedure? a. When changing the dressing, the tape should be removed rapidly from the edges. b. To ensure easy removal of the suture, the dressing should be keep dry c. The skin incision should be kept moist by periodically wetting the dressing d. The incision should be protected from fecal contamination by an intact dressing Correct D 94- While eating at a restaurant, a gravid woman begins to choke and is unable to speak. What action should the nurse who witness the event take? a. Cardiopulmonary resuscitation with uterine tilt b. The Heimlich maneuver using chest thrusts c. The Heimlich maneuver using subdiaphragmatic thirsts d. Call 911 immediately than begin cardiopulmonary resuscitation Correct B 95- A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium loaded in a vaginal applicator. What action should the nurse implement? a. Wear a dosimeter film badge when in the client’s room b. Spend 30 minutes at the bedside when clustering direct care c. Change the linens every day after providing a bed bath d. Use gloves to remove the applicator if it is dislodged in the bed Correct A 96- A client has a history of vasovagal attacks resulting in brady-dysrthmias. Which instruction is most important to include in the teaching plan? a. Use stool softeners regularly b. Avoid electromagnetic fields c. Maintain a low fat diet d. Do not use aspirin products Correct A 97- Which behavior is most likely to result in a breach of client confidentiality? a. Discussing a client’s condition during a teaching conference for nursing staff caring for the client b. Two nurses planning a client’s care while having lunch in the hospital cafeteria c. Nursing students on the same team discussing their assigned client’s conditions d. A registered nurse privately sharing personal feelings about a client with another nurse on the team. Correct B 98- A female client tells the clinic nurse that she has doubts of binge eating but cannot make herself vomit after meals. Which action by the nurse provides data to support the suspected diagnosis of bulimia? a. Ask the client to complete a food diary for the last 3 days b. Review the client’s lab data to determine her TSH, T2 and T4 levels. c. Interview the client about her use of laxatives and diuretics d. Encourage the client to describe her daily exercise regimen Correct C 99- The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant’s clinical picture? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory alkalosis d. Respiratory acidosis Correct B 100- A high school football player comes to the clinic complaining of severe acne. The mother reports recent behavior changes, including irritability and suspiciousness of friends. The nurse’s assessment reveals an elevated blood pressure. Which intervention should the nurse implement first? a. Encourage the client to see a dermatologist b. Refer the adolescent to a substance abuse program c. Suggest a low-salt, low fat, and caffeine free diet d. Inquire about a possible use of anabolic steroids Correct D 101- Which assessment is most important for the nurse to perform before ambulating a client with a history of syncope? a) Pedal pulses b) Breath sounds c) Oxygen saturation d) Blood pressure Correct D 102- A male client with schizophrenia is jerking his neck and smacking his lips. Which finding indicates to the nurse that he is experiencing an irreversible side effect of antipsychotic agents? a) Cramping muscular pain b) Worming movements of tongue c) Decreased tendon reflexs d) Dry oral mucous membranes Correct B 103- What assessment data should lead the nurse to suspect that a client has progressed from HIV infection to AIDS? a) Cervical lymph nodes are enlarged and tender b) Presence of low grade fever and sore throat c) Recent history of recurrent pneumonia d) CD4 blood cell count of 300 Correct C 104. A community health nurse is preparing to apply for a federal grant for an educational program about smoking cessation. In which order should the nurse prioritize the nursing activities? Arrange the activities in the order from first on top to last on bottom 5Develop a plan of action to educate the target population 1Determine the target aggregate that will be served by the 3Select and train the data collection personnel 2Consider the pros and cons of different methods of data 4Review and analyze the data 105. A client is admitted with acute low back pain. What action should the nurse implement to promote comfort? a. Ambulate using a walker for upper body support b. stretch the back ,uscles using abdominal curls c. Position in semi-Fowler's with the knees flexed d. Encourage straight leg raises while lying supine. Correct C 106. The nurse is performing a surgical hand scrub prior to entering the operating room. In what order should the nurse perform the steps of this procedure? Top to last Rinse from the fingertips to the elbow Scrape under the nails with a nail pick Use a soapy brush to scrub the hands Cleanse the arm with a lathered brush 107. A male client who fell into the lake while fishing and was submerged for about 3 min was successfully resuscitated by his friends. He was brought to the Emergency Department for evaluation and was admitted for a 24hr uneventful hospital stay. a) Avoid smoke filled environments b) Seek medical care promptly if a fever develops c) Increase oral fluids if a cough becomes productive d) Schedule frequent rest periods Correct B 108. Which action should the nurse implement when assessing a client's blood pressure and determining that there is an auscultate gap? a. Compare the palpated systolic blood pressure with the auscultated pressure b. Assess the client for lightheadedness with routinely occurs upon standing c. Determine if an automated blood pressure reading is consistent with the manual d. Observe for a change in blood pressure when comparing lying and sitting positions Correct A 109. Identify the placement of the stapes footplate into the bony labyrinth. (click the chosen location) la imagen esta en el medio donde hay que tocar 110. A 60 yr old male with type 2 diabetes mellitus tells the nurse that he is going to join a gym and star working out. Which information is most important for the nurse to obtain? a. Recent serum cholesterol blood levels b. Presence of calf pain during exercise c. Average weight gain or loss in the last year d. Exercise tolerance test with EKG results Correct D 111. A client is receiving an IV infusion of regular 75 unit in 100 ml of normal saline at 9 unit/hr. The nurse should program the infusion pump to deliver how many ml/hr? ANS 7 Use the formula desired dose/ available dose 9units/hour / 75 units x 100 ml = 12 112. A 14 yr old male client with a spinal cord injury (SCI) at T-10 is admitted for rehabilitation. During the morning assessment, the nurse determines that the adolescent's face is flushed, his forehead is sweating, his heart rate is 54 beats/min, and his blood pressure is 198/118. What action should the nurse implement first? a. Determine if the urinary bladder is distended b. Irrigate the indwelling urinary catheter c. Review the temperature graph for the last day d. Administer an antihypertensive agent Correct A 113. A new mother asks the nurse if the newborn infant has an infection because the healthcare provider prescribed a blood test called the TORCH screen test. Which response should the nurse offer to his mother's inquiry? a. Rising liters identify the etiology of certain neuro-sensory birth defects b. The screen determines the risk for inherited anomalies in the newborn c. The test identifies the correct antibiotic to give the newborn for an infection d. Exposure to infections that can cross the placenta cause a positive antibody liter Correct D 114. Which techniques should the nurse use to administer an intradermal (ID) injection for a Mantoux test to screen for tuberculosis (TB). Select all that apply a. Observe for an interdermal bled after the antigen is injected b. Select an ID site using the scapular region of the upper back c. Use a 25 gauge 1/2 inch needle on a 1 ml calibrated syringe d. Ensure that the needle is inserted into the skin with the level up e. Insert the needle at a 45 degree angle to the skin surface f. Massage the area after the injection to ensure absorption Correct D.C, A 115. Following rectal surgery, a female client seems very anxious about the pain that she may experience during defecation. The nurse should collaborate with the healthcare provider to administer which type of medication? a. Bulk-forming agent b. Antianxiety agent c. Stool softener d. Stimulant cathartic Correct C 116. The mother of a teenager is told that her son has recently been found stealing from other students at school. The mother's response is. " I cannot think about that today". The nurse determines that this mother is using which defense mechanism? a. Suppression b. Repression c. Sublimation d. Undoing Correct A 117. Which nursing entry to the client record best reflects significant data on a male client who is admitted with complaints of chest pain? a. Nurse will check client q1h for the presence of chest pain b. Client has a nervous, tense personally and likely to overreact c. Client states he will notify the nurse if chest returns d. Client understands how to use the call button and the telephone Correct C 118. A 37 yr old client diagnosed with chronic kidney disease (CKD) is being treated for renal osteodystrophy. Which nursing diagnosis is most likely to be included in this client's plan of care? a. High risk for infection related to subclavian catheter b. High risk injury related to ambulation c. Knowledge deficit related to high-protein diet d. Hygiene self-care deficit related to urenic frost. Correct B 119. The nurse is performing an admission assessment on a HIV positive client with a diagnosis of Pneumocystis carinii pheumonia (PCP). The nurse should carefully observe the client for which symptoms? a. Weight loss exceeding 10 percent of baseline body weight b. Altered mental status and tachypnea c. Creamy white patches in the oral cavity d. Normal ABGs with wet lung sounds in all lung fields Correct B 120. A 10 month old girl is admitted with a diagnosis of possible cystic fibrosis. What question should the nurse ask the patient about their child to assist in the diagnosis of cystic fibrosis (CF)? a. When you kiss her does she taste salty? b. Do you notice if her urine has a musty odor? c. Has she been drinking cow's milk in her daily diet? d. How often does she have a normal bowel movement? Correct A 121. Parents who have one male child with sickle cell anemia are concerned about having more children with the disease. What client teaching should the nurse provide? a. All future children will be carries, but will not have the disease b. There is a chance that each future child will have the disease c. Only male children can inherit the sickle cell disease trait d. Only one out of four of their children will manifest the disease Correct B 122. A client with rheumatoid arthritis reports a new onset of increasing fatigue. What intervention should the nurse implement first? a. Obtain a wheelchair for the client b. Explain to the client that this is an expected symptom c. Assess the client for pallor d. Obtain a sedative-hypnotic prescription Correct C 123. Which laboratory finding should the nurse expect to see in a child with acute rheumatic fever? a. Thrombocytopenia b. Polycythemia c. Decreased ESR d. Positive ASO liter Correct D 124. A client who is scheduled to have surgery in two hr tells the nurse. " My doctor was here and used a lot of big words about the surgery, then asked me to sign a paper." What action should the nurse take? a. Reassure the client that pre surgery anxiety is a normal experience b. Explain the surgery in clear terms that the client can understand c. Call the surgeon back to clarify the information with the client d. Redirect the client’s thoughts by teaching relaxation techniques Correct C 125. When the nurse is designing a plan of care for a client diagnosed with pheochromocytoma, a goal statement should be prepared that relates to which topic? a. Psychological counseling to address body image changes b. Medication teaching concerning thyroid hormones c. Preoperative and postoperative teaching for adrenalectomy d. Client and family referral to a hospice Correct C 126. A client is being treated for minor injuries following an automobile accident in which the only other passenger was killed. The client ask the nurse. " Is my friend who was in the car with me ok"? What response is best for the nurse to provide? a. "I am sorry, but you friend was killed in the accident" b. "Right now you need to concentrate on getting well" c. "was the passenger in the car your friend?" d. "I think you friend is going to be all right" Correct A 127. To differentiate adventitious lung sounds associated with heart failure from those associated with bacterial pneumonia. What information should the nurse review? a. Sputum culture findings b. Oxygen saturation level c. Amount of coughing d. Respiratory rate Correct A 128. A two yr old boy begins to cry when his mother starts to leave. What is the nurse's best response in this situation? a. "Let's wave bye=bye to Mommy" b. "Let me read this book to you" c. "Two yr old usually stop crying the min the parent leaves" d. "Now, now, be a big boy Mommy will be back soon" Correct B 129. A premature infant weighing 1.200 gr at birth receives a prescription for beractant (Survanta) 120 mg endotracheal now and q6 hr for 24 hr. The recommended dose for beractant is 100 mg/kg birth weight per dose. Single use vials of Survanta are labeled, 100 mg/4 ml. What action should the nurse take? a. Give 4.8 ml q6 hr b. Notify the healthcare provider that the dose is too high c. Notify the healthcare provider that the dose is too low d. Give 1.2 ml q6 hr Correct A 130. Several clients on a busy antepartum unit are scheduled for procedures that require that informed consent. Which situation should the nurse explore further before witnessing the client's signature on the consent form? a. The client was medicated for pain with a narcotic analgesic IM 6hr ago b. A 15 yr old primagravida who has been self-supporting for the pas 6 month c. The obstetrician explained a procedure that a neurologist will perform d. The client is illiterate but verbalize understanding and consent for the procedure Correct C 131. An 8 yrs old child who weighs 60 pounds receives an order for polycillin (Ampicillin) suspension 25 mg/kg/day divided in a dose every 8hr. The medication is labeled "125mg/5ml". How many ml should the nurse administer? ANS 5 132. A 3 yr old comes to the clinic for a well-child check up. Which respiratory assessment finding should the nurse expect this child to exhibit? a. A resting respiratory rate of 40 breaths per min b. Bronchovesicular breath sounds in the peripheral lung fields c. Retractions in the intercostal spaces with each inspiration d. high-pitched whistling sounds over the bronchus Correct B 133. The charge nurse is making assignment for clients on an endocrine unit. Which client is best to assign to a new graduate nurse? a. A female adult with hyperthyroidism who is returning to the unit after a thyroidectomy b. A male adult with Cushing's syndrome who reports a headache and visual disturbances c. An older man with Addison's disease who is diaphoretic and has hand tremors d. A Premenopausal woman with Graves' disease with is nervous and has exophthalmos Correct D 134. A client is admitted with a medical diagnosis of acute pancreatitis. When taking a health history, which client complaint should be expected? a. A low-grade fever and left lower abdominal pain. b. Severe headache and sweating all the time c. Severe mid-epigastric pain after ingesting a heavy meal d. Dull, continues, right lower quadrant pain and nausea Correct C 135. The nurse is planning care for a family whose children did not receive childhood immunizations. After one of the children contracted mumps, the father is diagnosed with orchitis. Which intervention should be included in the father's plan of care? a. Use of bedrest with scrotal support b. Administration of antibiotics for 10 days c. Applying heat to promote the healing process d. Using an ice pack to reduce scrotal pain Correct A 136. A newborn whose mother is HIV positive is admitted to the nursery from labor and delivery. Which action should the nurse implement first? a. Initiate treatment with zidovudine (ZDV) syrup at 2 mg per kg b. Bathe the infant with dilute chlorhexidine (Hibiclens) or soap c. Measure and record the infant's frontal-occipital circumference d. Administer vitamin K (AquaMEPHYTON) IM in the vastus lateralis Correct B a) 137. A grant is awarded to provide primary preventative health care to a community based healthcare system. When designing the program to meet the grant objective, which service should the nurse consider for inclusion in the program? Select all that apply b) a. Breast screening for older women b. Rehabilitation services for stroke victims c. Blood pressure assessments d. Antepartal nutritional counseling e. Ambulatory oncology treatments f. Emergency services for trauma victims Correct A,C,D 138. An adult male who admits to abusing IV drugs obtains the results of HIV testing. When informed that the results are positive, he states that he does not want his wife to know. What action should the nurse take? c) Tell the client he is required by law to inform his sexual partners of his HIV status d) Counsel the client about the importance of notifying his sexual partner e) Inform the wife of her health risk related to her husband's HIV results f) Report the client's as a sexually transmitted case to the health department Correct B 139. Two hr after delivering a 9 pound infant, a client saturates a perineal pad every 15 min. Although an IV containing Pitocin is infusing, her uterus remains boggy, even with massage. The healthcare provider prescibes methylergonovine maleate (Methergine) 0.2 mg IM STAT. Which complication should the nurse be alert to this client developing? a. Decreased respiratory rate b. Increased temperature c. Tachycardia d. Hypertension Correct D 140. When assessing a client several hr after surgery, the nurse observes that the client grimaces and guards the incision while moving in the bed. The client is diaphoretic, has a radial pulse rate of 110 beats/min, and a respiratory rate of 35 breath/min. What assessment should the nurse perform first? a. Apical heart rate b. IV site and fluids c. Pain scale d. Temperature Correct C 141. A man calls the hospital and ask to talk with the nurse about his girlfriend who was extremely intoxicated on admission and is receiving services for detoxification. He knows that she is in the facility and ask the nurse about her condition. What is the nurse's best response? a. : I can only report that the client is in satisfactory condition" b. "Let me give you the telephone number for her room: c. : I cannot acknowledge if a client is here or not" d. " I will have the nurse who is working with her call you" Correct C 142. The medical record of a child with Duchenne muscular dystrophy (MD) states a Gower sign is present. Based on this documentation, the nurse should expect the child to exhibit which behavior? a. Stands from sitting on the floor by using hands to walk up legs b. Exhibits muscular atrophy of upper and lower extremities c. Is unable to stand because of contractures of both hips d. Walks with an unsteady gait and slaps feet on floor Correct A 143. Which situation is a violation of the client confidentiality, as described in the Health Insurance Portability Accountability Act (HIPAA)? a. A sign sheet kept at the front desk listing client's last names and time of their arrival b. A nurse's handwritten notes from a telephone report discarded in the office wastebasket c. A computer monitor screen that is located at the nurse's station in a high traffic area d. Privileged Heath Information (PHI) given to an ambulance friver for transfer of a client Correct B 144. The nurse observes that a client who is to avoid any weight bearing on the left leg is using a 3 point crutch gait for ambulation. What is the best action for the nurse to initiate? a. Encourage continued use of the 3 point gait by the client b. Encourage the client to use a wheelchair for mobility c. Instruct the client in the use of a 4 pint crutch gait d. Instruct the client in the use of a 2 point crutch gait Correct A 145. The nurse is caring for a comatose client. Which assessment finding provides the greatest indication that the client has an open airway? a. The client has asymmetrical chest expansion b. Percussion reveals dullness over the lung area c. Bilateral breath sounds can be auscultated d. The client has been turned q2h Correct C 146. The healthcare provider prescribes lidocaine (Lidoject-1) 100 mg IV push for ventricular tachycardia (IV) for an unconscious client. What is the nurse's priority intervention? a. Measure the client's cardiac output b. Assess neurological status q15 min c. Collect a blood specimen for a serum potassium d. Infuse lidocaine (Lidoject-1) at 20 to 50 mg/min Correct D 147. A client who sustained a pellet gun injury with a resulting comminuted skull fracture is admitted overnight for observation. Which assessment finding obtained two hours after admission necessitates immediate intervention? a. The client complains of a throbbing headache rated 10 (1 to 10 scale) b. The client repeatedly falls asleep while talking with the nurse c. The entry site has a slow trickle of bright red blood d. The entry site appears reddened and edematous Correct B 148. A male client, admitted to the mental health unit for a somatoform disorder, becomes angry because he cannot have his pain medication. He demands that the nurse call the healthcare provider and threatens to leave the hospital. What action should the nurse take? a. Place the client in seclusion per unit guidelines b. Administer a PRN prescription for lorazepam (Ativan) c. Call security to help ensure staff and client safety d. Ask what other methods he uses to deal with pain Correct D 149. While flushing the proximal port of a triple lumen central venous catheter with heparin solution, the nurse meets resistance. What action should the nurse take? a. Remove the cap and apply direct gentle pressure with the syringe b. Contract the healthcare provider regarding the need for a chest x-ray c. cover the cap with tape and label the port as being obstructed d. Remove the catheter while applying gentle pressure at the insertion site Correct C 150. A client is admitted to the hospital with a serum sodium level of 128 mEq/L, distended neck veins, and lung crackles. What intervention should the nurse implement? a. Increase the intake of salty foods b. Administer NaCl supplemets c. Restrict oral fluid intake d. Hold the client's loop diuretic Correct C 151. A female client presents to the emergency department in the early evening complaining of abdominal cramping, watery diarrhea, and vomiting. She tells the nurse that she was at a picnic and ate barbeque that afternoon. What que