HESI PN EXIT EXAM NGN Q&A 2023/24 UPDATE

HESI PN EXIT EXAM NGN Q&A 2023/24 UPDATE HESI PN EXIT EXAM NGN Q&A 2023/24 UPDATE I HAVE MERGED 3 FILES WHICH THEY ARE TESTING FROM INCLUDING SOME CASE STUDIES NORMAL QUESTIONS ON ACTUAL TEST IS 90% WHILE NGN IS ABOUT 10% THIS FILES CONTAINS SOME RATIONALES TOO 1. A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulindependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER? Regular insulin by IV infusion 2. A 68-year-old male presents with shortness of breath, chest pain, and fatigue. His medical history includes hypertension and hyperlipidemia. What condition should the nurse suspect based on these symptoms? The nurse should suspect the patient is experiencing a myocardial infarction (heart attack). 3. A 6-year-old child is brought to the emergency department with sudden onset of high fever, sore throat, and difficulty swallowing. The nurse observes the child leaning forward with the mouth open and drooling. What condition is the child most likely experiencing? The child is most likely experiencing epiglottitis, a potentially life-threatening infection causing inflammation of the epiglottis. 4. A female client has been treated since childhood for mitral valve prolapse. The antibiotic of choice for her during pregnancy would be: Erythromycin 5. A client is being admitted to the labor and delivery unit. She has had previous admissions for “false labor.” Which clinical manifestation would be most indicative of true labor? Progressive dilatation and effacement of the cervix 6. A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to: Cry 7. A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three- way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent: Clot formation 8. A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nägele’s rule is: February 27 9. The therapeutic blood-level range for lithium is: 0.5–1.5 mEq/L 10. Which of the following ECG changes would be seen as a positive myocardial stress test response? ST-segment depression 11. A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion? Grandiose 12. During burn therapy, morphine is primarily administered IV for pain management because this route: Facilitates absorption because absorption from muscles is not dependable 13. Assessment of the client with pericarditis may reveal which of the following? Pericardial friction rub and pain on deep inspiration 14. A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to: Perform a halo test and glucose level on the drainage 15. To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following? A. Positive inotropic therapy 16. The most important reason to closely assess circumferential burns at least every hour is that they may result in: Loss of peripheral pulses 17. A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record: 3-1-1-0-2 18. A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level? 14 µ g/mL 19. A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53. This client is most likely experiencing: Metabolic alkalosis 20. A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention? Decreased inspiratory difficulty 21. Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include: Cleanse area around the meatus twice a day 22. A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self- mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by: Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area 23. A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate (Vanceril) to be administered via inhalation three times a day and at bedtime. Client teaching regarding the sequential order in which the drugs should be administered includes: Bronchodilator followed by the glucocorticoid 24. A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to: Have the client void and then re-evaluate the fundus 25. During a client’s first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus. This may be due to: Urine retention or a distended bladder 26. 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 27. The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth) • 0.4 28. nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? • Auscultate the client's bowel sounds • Observe for edema around the ankles • Measure the client’s capillary glucose level • Count the apical and radial pulses simultaneously 29. A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants “no heroic measures” taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? Ask the client to discuss “do not resuscitate” with her healthcare provider 30. A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour 31. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? Have you noticed any changes in your fingernails? 32. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? • Capillary refill of 8 seconds 33. After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse’s signature on the client’s surgical consent form? (Select all that apply) • The client voluntarily grants permission for the procedure to be done • The client is competent to sign the consent without impairment of judgment • The client understands the risks and benefits associated with the procedure 34. Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? Advise the client that assignments are not based on clients requests 35.A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? Place the implant in a lead container using long-handled forceps 36. The client with which type of wound is most likely to need immediate intervention by the nurse? • Laceration 37. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client’s plan of care? Monitor blood pressure frequently 38. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? • To reduce abdominal pressure on the diaphragm 39. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? • The client is too obese 40. A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? • describe the transmission of drugs to the infant through breast milk 41. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? • Start an intravenous (IV) infusion of normal saline 42. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medication? increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure 43. Which client is at the greatest risk for developing delirium? An adult client who cannot sleep due to constant pain. 44. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? Reduce risks factors for infection 45. Which location should the nurse choose as the best for beginning a screening program for hypothyroidism? • A business and professional women's group. 46.A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling “very tired”. Which nursing intervention is most important for the nurse to implement? • Measure vital signs 47.A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider? • capillary glucose 48.What explanation is best for the nurse to provide a client who asks the purpose of using the log- rolling technique for turning? • working together can decrease the risk for back injury 49.A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client? • Baked apples topped with dried raisins 50. Which action should the school nurse take first when conducting a screening for scoliosis? • Inspect for symmetrical shoulder height. 51. An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement? • Assign a practical nurse (LPN) to determine if an apical radial deficit is present 52. After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client’s discharge plan? • Encourage a low-carbohydrate and high-protein diet 53. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform? • Observe the antecubital fossa for inflammation. 54. The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication’s effectiveness, which laboratory values should the nurse monitor? Select all that apply • White blood cell (WBC) count • Sputum culture and sensitivity 55. A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement? • Negative pressure environment 56.A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child? • Sitting up and leaning forward 57.A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? • Altered consciousness within the first 24 hours after injury. 58.A female client with breast cancer who completed her first chemotherapy treatment today at an out- patient center is preparing for discharge. Which behavior indicates that the client understands her care needs • Rented movies and borrowed books to use while passing time at home 59.Which instruction should the nurse provide a pregnant client who is complaining of heartburn? • Eat small meal throughout the day to avoid a full stomach. 60.A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? • Hypokalemia 61.A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement? • Digitally check the client for a fecal impaction 62. After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse? • Bilateral Wheezing. 63. The nurse should teach the parents of a 6 year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response? • Inflammation of the mucous membrane & bronchospasm 64.A 10 year old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond? • "The heart will stop beating & you will stop breathing." 65. The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply: • Restlessness • Clenched Fist • Increased pulse rate • Increased respiratory rate. 66. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication? • Determine which side of the body is weak. 67. The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse? • Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. 68. The nurse is caring for a client who had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours? • Measure hourly urinary output. 69. When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement? • Schedule an appointment for an out-patient psychosocial assessment. 70. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first? • Explore client’s readiness to discuss the situation. 71. In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor? • Glucose 72. Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrentchlamydia. What information is most important for the nurse to provide to this client? • Use two forms of contraception while taking this drug. 73.A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication? • Divalproex. 74.A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? • Serum lithium level of 1.6 mEq/L or mmol/l (SI) 75.A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client’s EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, “I feel like an elephant just stepped on my chest” The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform? • Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula. 76.The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan? • Literacy level 77.A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet? • Eat approximated the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. 78. A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention. • Maintain contact transmission precaution 79. A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/minute. What action should the nurse take? • Administer Naxolone IV 80. Which intervention is most important for the nurse to include in the plan of care for an older woman with osteoporosis? • Place the client on fall precautions 81. Based on the information provided in this client’s medical record during labor, which should the nurse implement? (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.) • Continue to monitor the progress of labor. 82. A nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department for treatment on the evening shift. The nurse would assign the highest priority to which of the following clients? 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce 83. A nurse enters a client’s room and notes that the client’s lawyer is present and that the client is preparing a living will. The living will requires that the client’s signature be witnessed, and the client asks the nurse to witness the signature. Which of the following is the appropriate nursing action? 1. Decline to sign the will. 84. A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? Select all that apply. 3. “I need to limit playing football to only the weekends.” 5. “I should exercise in the evening to encourage a good sleep pattern.” 85. A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously 86. A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply. 2. Early onset cough 4. Purulent mucus production 5. Mild episodes of dyspnea 87. A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client’s efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis? 3. Inquiring about the client’s feelings that may affect coping 88. A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client’s hospital gown? 2. Disconnecting the IV tubing from the catheter in the vein 89. A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first? 1. A client on a ventilator 90. A nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection? 2. Psychosocial 91. A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply. 1. Wearing gloves when emptying the client’s bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a film (dosimeter) badge when in the client’s room 4. Wearing a lead apron when providing direct care to the client 92. The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that 5. In a semi-Fowler’s position 6. With the head in a midline position 93. A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to: 3. Treat hypocalcemic tetany. 94. A nurse is caring for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure? 3. Gloves, a gown, and goggles 95. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation? 2. Metabolic alkalosis 96. A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Based on this documentation, which of the following did the nurse most likely 4. Respirations that are abnormally deep, regular, and increased in rate 97. Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply. 1. Monitor for hemorrhage. 2. Administer eye medications. 3. Maintain the eye patch or shield. 4. Assist with activities of daily living. 6. Educate regarding symptoms of retinal detachment. 98. A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present? 4. Postural blood pressure changes 99. A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications? 3. A 10-year-old female client with a urinary tract infection 100. A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply. 2. Notify the registered nurse. 4. Prepare to administer morphine sulfate. 5. Prepare to administer intravenous fluids. 6. Prepare to administer 100% oxygen by face mask. 101. A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply. 1. Oliguria 4. Proteinuria 3+ 6. Blood pressure 168/116 mm Hg 102. A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation? Select all that apply. 1. Partial thromboplastin time. 2. Prothrombin time. 3. Platelet count. 103. A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that apply. 2. Increased clotting time. 3. Hypertension. 4. Headaches. 104. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be MOST likely to prompt parents to take their school age child for evaluation? C) Bed wetting 105. The nurse practicing in a maternity setting recognizes that the post mature infant is at risk due to D) Progressive placental insufficiency 106. The nurse is preparing to administer an enteral feeding to a client via an nasogastric feeding tube. The MOST important action of the nurse is A) Verify correct placement of the tube 107. The major purpose of community health research is to A) Describe the health conditions of populations 108. While assessing the quality of home care for a client with Alzheimer's disease, the PRIORITY for the nurse is to emphasize C) Client safety 109. A postpartum woman admits to alcohol use throughout the pregnancy. Which of the following newborn assessments suggests to the nurse that the infant has fetal alcohol syndrome? C) Cranial facial abnormalities are noted 110. A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the following medications should the nurse anticipate the provider to prescribe? Naloxone 111. A client on bed rest refuses to wear the prescribed pneumatic compression device after surgery, what action should the PN implement in response to the clients refusal – emphasize the importance of active foot flexation 112. After applying alcohol based hand rub to the palms of the hand and rubbing the palms together what action should the pn take next – place hands on top of each other and interlace fingers 113. A new mother is bottle feeding instead of breastfeeding the practical nurse should instruct to most effective way to deal with breast engorgement and discomfort is to – wear a supportive bra at all times 114. Because of staffing shortages the charge nurse assigns a practical nurse to perform a skill which the PN is not yet not certified to perform what is the best response by the PN – I am uncomfortable performing a skill when i am not certified 115. Client recovering from stroke is learning how to use cane how should it be placed – on the stronger side of the body 116. Schizophrenia is withdrawn isolates himself in the day room and answers questions with one or two word responses which intervention is most important- measure appropriate vital signs 117. While performing the apical pulse of an adult male client the practical nurse notes that the point of maximal impulse is located at the 4th intercostals space medial to the midclavicular line what is the assessment for – expected finding 118. Type 2 diabetes becomes unresponsive and says im not feeling right which action should the pn take – give 4 ounces of apple juice 119. A new mother is breastfeeding her newborn for the first time and complains of nipple pain when the baby sucks what should the nurse tell the mom- ensure that all the areola tissue of the nipple is in the infants mouth 120. A client with irritable bowel syndrome is receiving dicyclomine an anticholinergic drug – provide oral care 121. The pn is caring for a client in bucks traction what is the priority goal for the client in traction- maintain straight body alignment 122. Which site should the pn use when administering RHO D- deltoid 123. Client with hungtingtons diesease starts jerking around while the family is there what should the nurse do – offer emotional support to the family 126. When should a person use additional birth control precautions- when taking antibiotics for an infection 127. Client who has four gold seed implants on a chest wall tumor is on radiation precautions what basic precautions should the pn nurse observe when administering direct client care- minimal time maximum distance and protective shielding 128 Mrs. Emilly, a 68-year-old female, presents to the emergency department with severe abdominal pain and distension. She has a history of diverticulitis and is experiencing nausea and vomiting. The nurse suspects a possible bowel obstruction. A. What are the common causes of bowel obstruction? Common causes of bowel obstruction include adhesions, hernias, tumors, and strictures. B. What are the clinical manifestations of bowel obstruction? Clinical manifestations of bowel obstruction include abdominal pain, distension, constipation, nausea, vomiting, and decreased or absent bowel sounds. 129. Mr. Rambo, a 55-year-old male, is admitted to the hospital with a diagnosis of pneumonia. He has a history of chronic obstructive pulmonary disease (COPD) and is experiencing increased shortness of breath and productive cough. A. What are the risk factors for developing pneumonia? Risk factors for developing pneumonia include advanced age, smoking, chronic lung diseases (such as COPD), immunosuppression, and aspiration. B. What are the common causative organisms of pneumonia? The most common causative organisms of pneumonia include Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma pneumoniae. 130. Ms. Thompson, a 45-year-old female, is admitted to the medical-surgical unit with a diagnosis of acute myocardial infarction (AMI). She underwent a percutaneous coronary intervention (PCI) with stent placement. A. What are the signs and symptoms of an acute myocardial infarction? Signs and symptoms of an acute myocardial infarction include chest pain or discomfort, shortness of breath, diaphoresis, nausea, and vomiting. B. What is the purpose of a percutaneous coronary intervention (PCI)? The purpose of a PCI is to restore blood flow to the blocked coronary artery by dilating the vessel and placing a stent to keep it open. 131. Mr. Davis, a 62-year-old male, is admitted to the psychiatric unit with a diagnosis of major depressive disorder. He presents with symptoms of sadness, loss of interest, and feelings of worthlessness. A. What are the common symptoms of major depressive disorder? Common symptoms of major depressive disorder include persistent sadness, loss of interest or pleasure, changes in appetite and sleep patterns, fatigue, feelings of worthlessness or guilt, difficulty concentrating, and thoughts of death or suicide. B. What are the treatment options for major depressive disorder? Treatment options for major depressive disorder may include psychotherapy, antidepressant medications, and in severe cases, electroconvulsive therapy (ECT). 132. Mrs. Smith, a 75-year-old female, is admitted to the long-term care facility with a diagnosis of Alzheimer's disease. She exhibits memory loss, confusion, and difficulty with daily activities. A. What are the common signs and symptoms of Alzheimer's disease? Common signs and symptoms of Alzheimer's disease include memory loss, confusion, difficulty with problem-solving and language, changes in mood and behavior, and eventual loss of ability to perform daily activities. B. What are the nursing interventions for patients with Alzheimer's disease? Nursing interventions for patients with Alzheimer's disease may include providing a safe and structured environment, promoting independence in self-care activities, offering reassurance and emotional support, and educating family members about the disease process 133. A client with small bowel obstruction is experiencing frequent vomiting which instructions are most important for the practical nurse to provide to the unlicensed personnel who is completing morning care for this client – measure all emesis accurately 134. A 24-hours’ postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first: Assist her with a sitz bath 135. Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients? Thiamine and pyroxidine CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT CHRISJAY COPYRIGHT V2 1. A nurse is assisting the charge nurse with the preparation for an in-service about negligence for a group of newly licensed nurses. Which of the following scenarios should the charge nurse use as an example to identify negligence? Answer: A nurse does not notify the provider of a change in condition for a client who has schizophrenia 2. A nurse in a provider’s office is collecting data from an older adult client whose adult child reports that she “seems confused and can’t seem to remember much.”Which of the following findings should lead the nurse to suspect delirium? Answer: The client’s level of consciousness changes during the interview 3. A nurse is caring for a client who gave birth to a stillborn fetus one week ago. She statesto the nurse,”I am so angry that my doctor didn’t take better care of me and my baby.” Which of the following responses should the nurse make? Answer: It is important to share what you are feeling, even if it is anger 4. A nurse is contributing to the plan of care for a client who has borderline personality disorder and exhibits manipulative behaviors. Which of the following interventions should the nurse include in the plan to address limit setting? Answer: Establish and explain consequences for the client’s behavior 5. A nurse is caring for an adult client who has visible injuries as a result of intimate partner violence. Which of the following actions should the nurse take? Answer: Encourage the client to develop a safety plan 6. A nurse in an urgent care clinic is collecting data from a client whose friend reports a suspicion of cocaine use. The nurse should identify that which of the following manifestations is an indicator of the client’s use of this substance? Answer: Hypertension 7. A nurse in a mental health facility is caring for a client who has dementia. The client’s agitation is increasing. Which of the following actions should the nurse take first? Answer: Offer diversionary activities 8. A nurse is caring for a client who has bipolar disorder. The client suddenly appears agitated and begins pacing at the end of the hallway with clenched fists. Which of the following actions should the nurse take first? Answer: Determine the client’sintentions 9. A nurse isreinforcing discharge teaching with a client who has a new prescription for alprazolam. Which of the following instructions is the priority for the nurse to include? Answer: Do not drive until your reaction to the medication is determined 10. A nurse is caring for a client who is 2 days postoperative following a hip arthroplasty. When a news report about military action comes on the television, the client says to the nurse, “My youngest child died 6 months ago while serving in the military.” Which of the following responses should the nurse make? Answer: -This must be very difficult time for you -Your child’s death must be a terrible loss -Tell me something you remember about your child 11. A nurse is contributing to the plan of care for a client who has bipolar disorder and is exhibiting mania, Which of the following interventions should the nurse include to improve the nutritional status of the client? Answer: Have the client’sfavorite snacks available at all times. 12. A nurse is collecting data from a client who has paranoid personality disorder. Which of the following manifestations should the nurse expect? Answer: Projects blame onto others 13. A nurse on and inpatient unit is assisting with a group therapy session. During the session, a client begins to shout using aggressive language. Which of the following statements should the nurse make to the client? Answer: When you raise your voice, it makes me feel uncomfortable and unsafe.” 14. A nurse is caring for a client who has schizophrenia. Which of the following actions by the nurse is a violation of the client’s confidentiality? Answer: The nurse places the client’s diagnosis on the white board in the client’s room 15. A nurse in a mental health facility is collecting data from a client who has schizophrenia. The nurse should identify that which of the following findingsisreferred to as a negative symptom of schizophrenia? Answer: Apathy 16. A nurse in a long-term care center is caring for an adult client who has Alzheimer’s disease and whose partner died several years ago. The client appears upset and aslsthe nurse when his partner will visit again. The nurse states,”It seems like you are feeling lonely. Let’s take a walk outside and talk.’ Which of the following communication strategies is the nurse using? Answer: Validation therapy 17. A nurse is reinforcing teaching with a client who has schizophrenia and a new prescription for chlorpromazine. Which of the following statementsshould the nurse include in the teaching? Answer:” The voices you have been hearing should decrease.” 18. A nurse isreinforcing teaching with a client who has generalized anxiety disorder and is to start therapy with buspirone. Which of the following statementsshould the nurse identify as an indication that the client understands the information? Answer: “I should expect some improvement of my symptoms in about 10 days 19. A nurse is caring for a client who has major depressive disorder(MDD). The client states.”I have nothing to live for anymore. I just can’t go on.” Which of the following responses should the nurse make? Answer: Are you thinking about ending your life 20. A nurse at an outpatient mental health clinic is assisting with a group therapy session. One of the participants is having difficulty staying seated and states loudly to the therapist.”I know more than you do about the people in this room!” The nurse should identify that which of the following findings is the likely explanation for the client’s behavior? Answer: Hypomania 21. A nurse is assisting with a mental status examination for a client who has schizophrenia. Which of the following statementsshould the nurse make to gather information about the client’s ability to think abstractly? Answer: How is an orange similar to an apple 22. The nurse seeks to assess the renal function of an elderly client who is about to receive a nephrotoxic medication. Which of the following labs provides the best indicator for renal function? D. creatinine clearance 23. The nurse sustains a needle puncture that requires HIV prophylaxis. Which of the following medication regimens should be used? B. two non-nucleoside reverse transcriptase inhibitors 24. After securing the client’s safety from a faulty electric bed, the nurse should take which action? D. Prepare an incident report. 25. A client taking isotretinoin (Accutane) tells the nurse that she is pregnant. What should the nurse teach this client? A. Her pregnancy is threatened, and the fetus is at risk for teratogenesis. 26. When a drug is listed as Category X and prescribed to women of child-bearing age/capacity, the nurse and the interdisciplinary team should counsel the client that: B. She must use a reliable form of birth control. 27. How many feet should separate the nurse and the source when extinguishing a small, wastebasket fire with an appropriate extinguisher? D. 6 feet 28. While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take? A. Unplug the bed’s power source. 29. A mother has just given birth to a baby who died soon after. The mother has been crying and states, "I can’t believe this has happened to me. I did everything right during this pregnancy." How should the nurse respond to this mother? D. Tell her nothing and let her mourn this loss in the manner she chooses. 30. The difference between spirituality and religion is that spirituality is: B. an individual’s relationship with a higher power. CHRISJAY COPYRIGHT 31. Spirituality affects a client’s life in all of the following areas except: D. genetic makeup. 32. After the client discusses her relationship with her father, the nurse says, "Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?" This is an example of: B. seeking consensual validation. 33. Which of the following foods can cause diarrhea when eaten by a client with an ileostomy? B. coffee 34. In infants and children, the side effects of firstgeneration over-the counter (OTC) antihistamines, such as diphenhydramine (Benedryl) and hydroxyzine (Atarax), can include: C. paradoxical CNS stimulation. 35. The nurse can promote relief of muscle pain, spasms, and tension by: C. applying heat, cold, pressure, or vibration to the painful area. 36. When a couple experiencing infertility presents for a fertility workup, which of the following procedures should the nurse prepare the couple to have first? B. semen analysis 37. Which of the following actions should a nurse take first for a client who has just vomited 300 cc of bright red blood? D. Check the blood pressure. 38. Which of the following statements indicates adequate dietary understanding in a client with constipation? C. "I should increase my intake of apples." 39. Which cultural group has the highest incidence of inflammatory bowel disease (IBD)? B. Caucasians 40. Nail and foot care are essential in meeting basic hygiene needs of clients. Important assessments by the nurse in this area include: C. the nail beds and the tissue surrounding the nails. 41. For a client requiring total oral care, it is important for the nurse to: C. assemble all equipment, place the client in a side-lying position, and place a towel under his chin. 42. Client room environments should include: A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas. 43. A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which of the following information to the client? 4. “You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed.” 44. Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply. 1. A premature infant 2. A 101-year-old man 3. A client on renal dialysis CHRISJAY COPYRIGHT 6. A client with congestive heart failure 45. An unconscious client who is bleeding profusely is brought to the emergency department after a serious accident. Surgery is required immediately to save the client’s life. With regard to informed consent for the surgical procedure, which of the following is the best action? 4. Transport the client to the operating department immediately, as required by the health care provider without obtaining an informed consent. 46. When caring for a 3-year-old child, the nurse should provide which toy for this child? 2. A wagon 47. When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply. 2. Decline in visual acuity 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset 48. Which data indicates to the nurse that a client may be experiencing ineffective coping? 1. Constantly neglects personal grooming 49. The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would the appropriate nursing interventions be with this client? Select all that apply: 1. Use active listening skills to seek information from the client. 2. Encourage the client to describe the problem as she sees it. 3. Ask the client to tell you exactly what she thinks is happening. 50. Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Check all that apply: 2. Avoid use of donut type devices. 4. Elevate the HOB no more than 30 degrees when possible. 5. When the client is side lying, use the 30 degree lateral inclined position. 6. Avoid uninterrupted sitting in a chair or wheelchair. 51. The nurse is evaluating a client recently diagnosed with primary open angle glaucoma (POAG). What will an important nursing action be? Select all that apply: 1. Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect. 5. Have the client demonstrate the use of eye drops. 6. Assess the client for chronic diseases such as diabetes. 52. A nurse understands that a patient may experience pain during peritoneal dialysis because of which of the following? Select all that apply: 2. Too rapid installation 4. Accumulation of dialysate solution under the diaphragm 53. The nurse is evaluating a client’s response to hemodialysis. Which lab results will indicate the dialysis was effective? Select all that apply: 1. Serum potassium level decreases from 5.4 to 4.6 mEq/L 2. Cr decreases from 1.6 to 0.8 mg/dL 5. BUN decreases from 110 to 90 mg/dL CHRISJAY COPYRIGHT 54. The nurse understands that the following clinical findings are indications for dialysis. Select all that apply: 1. Volume overload 3. K 5.2 mEq/L 5. Metabolic acidosis 6. Cr 5.0 mg/dL 55. The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding would cause the nurse concern regarding the development of compartment syndrome? Select all that apply: 2. Paresthesia distal to area of injury. 3. Toes on affected leg cool to touch and edematous. 5. Complaints of leg pain unrelieved by analgesics or repositioning. 56. The nurse is preparing discharge for a patient with GERD. What would be important for the nurse to include in this teaching plan? Select all that apply: 1. Elevate the HOB. 2. Decrease intake of caffeine. 3. Discuss strategies for weight loss if overweight. 5. Take ranitidine (Zantac) at hs. 57. The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure. Select all that apply: 1. Verify consent has been signed. 2. Explain procedure to client. 5. Obtain a 12 lead ECG 6. Obtain history of shellfish allergy. 58. The nurse has been assigned a group of cardiac clients. What would be the most important information for the nurse to check on the initial evaluation of each client? Select all that apply: 1. Presence of cardiac pain. 3. Presence of jugular vein distention. 4. Heart sounds and apical rate. 5. Presence of diaphoresis. 59. The nurse is teaching a client about home care and treatment of venous stasis ulcers in his leg. What should be included in the nurse’s instructions? Select all that apply: 2. Healing will be facilitated by wearing leg compression devices. 3. When the client is in sitting position, he should keep his legs elevated. 4. Avoid standing for long periods of time. 60. A nurse knows the clinical manifestations of a client with Addison’s disease include which of the following? Select all that apply: 1. Nausea 4. Hyperpigmentation 5. Hypotension 61. A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice? CHRISJAY COPYRIGHT 3. Nursing staff are led by a nurse when providing care to a group of clients. 62. A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? 2. A client who requires frequent ambulation 63. A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client’s malpractice claim. Select all that apply. 2. Increased risk of hypotension 3. Failure to teach the client adequately 4. Increased need to protect the client 6. Lack of follow-up nursing actions 64. A client’s record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time? Tyramine-free 65. Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0? Vomiting, impaired consciousness, decreased blood pressure 66. A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum: Potassium level of 6.3 mEq/L 67. The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have: A low birth weight 68. A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulindependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER? Regular insulin by IV infusion 69. In teaching the client about proper umbilical cord care, the nurse recommends that: The area be cleansed at diaper changes with alcohol and inspected for redness or drainage 70. A 24-hours’ postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first: Assist her with a sitz bath 71. Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients? Thiamine and pyroxidine 72. A client with a closed head injury is receiving phenytoin (Dilantin), an anticonvulsant medication. Which CHRISJAY COPYRIGHT of the following would indicate that the client is experiencing side effects related to this medication? Select all that apply. 3. Constipation 4. Bleeding gums 5. Hyperglycemia 73. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply. 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Serum sodium blood levels 6. Medication that is antagonistic to antidiuretic hormone (ADH) 74. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply. 1. Radiation 2. Chemotherapy 4. Serum sodium blood levels 6. Medication that is antagonistic to antidiuretic hormone (ADH) 75. The clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which of the following would the nurse include for this type of data collection? Select all that apply. 1. Auscultating lung sounds 2. Obtaining the client’s temperature 4. Obtaining information about the client’s respirations 76. A community health nurse is conducting a teaching session about terrorism with members of the community and discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted via which route(s)? Select all that apply. 1. Skin 3. Inhalation 4. Gastrointestinal 77. The emergency room nurse is providing discharge teaching to the parents of a 2-year-old child who sustained burns from a hot cup of coffee that had been left on the kitchen counter. The nurse evaluates that the parents have correctly understood the teaching when they state which of the following? 1. “We will be sure to not leave hot liquids unattended.” 78. A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which of the following is a characteristic of this type of nursing model of practice? 3. Nursing staff are led by a nurse when providing care to a group of clients. 79. A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? CHRISJAY COPYRIGHT 2. A client who requires frequent ambulation 80. A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client’s malpractice claim. Select all that apply. 2. Increased risk of hypotension 3. Failure to teach the client adequately 4. Increased need to protect the client 81. A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply. 1. Monitor the client’s ability to void. 2. Maintain the client in a flat position. 3. Restrict fluid intake for a period of 2 hours. 4. Monitor the client’s ability to move the extremities. 5. Inspect the puncture site for swelling, redness, and drainage. 82. A nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department for treatment on the evening shift. The nurse would assign the highest priority to which of the following clients? 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce 83. A nurse enters a client’s room and notes that the client’s lawyer is present and that the client is preparing a living will. The living will requires that the client’s signature be witnessed, and the client asks the nurse to witness the signature. Which of the following is the appropriate nursing action? 1. Decline to sign the will. 84. A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? Select all that apply. 3. “I need to limit playing football to only the weekends.” 5. “I should exercise in the evening to encourage a good sleep pattern.” 85. A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously 86. A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply. 2. Early onset cough 4. Purulent mucus production 5. Mild episodes of dyspnea 87. A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client’s efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the CHRISJAY COPYRIGHT crisis? 3. Inquiring about the client’s feelings that may affect coping 88. A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client’s hospital gown? 2. Disconnecting the IV tubing from the catheter in the vein 89. A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first? 1. A client on a ventilator 90. A nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection? 2. Psychosocial 91. A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply. 1. Wearing gloves when emptying the client’s bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a film (dosimeter) badge when in the client’s room 4. Wearing a lead apron when providing direct care to the client 92. The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that 5. In a semi-Fowler’s position 6. With the head in a midline position 93. A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to: 3. Treat hypocalcemic tetany. 94. A nurse is caring for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure? 3. Gloves, a gown, and goggles 95. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation? 2. Metabolic alkalosis 96. A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Based on this documentation, which of the following did the nurse most likely 4. Respirations that are abnormally deep, regular, and increased in rate 97. Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply. 1. Monitor for hemorrhage. 2. Administer eye medications. 3. Maintain the eye patch or shield. 4. Assist with activities