NURSING MEDSURG 2 HESI EXAM QUESTIONS AND ANSWERS BEST RATED A+ GUARANTEED SUCCESS

NURSING MEDSURG 2 HESI EXAM QUESTIONS AND ANSWERS BEST RATED A+ GUARANTEED SUCCESS “In planning care for a 6-month-old infant, what must the nurse provide to assist in the development of trust? A) Food B) Warmth C) Security D) Comfort - CORRECT ANSWER C) Security" "Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies? A) Risk for injury B) Risk for knowledge deficit C) Altered thought process D) Disturbance in self-esteem - CORRECT ANSWER A) Risk for injury" "Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? A) Hemoglobin level of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A heart rate between 140 to 160 - CORRECT ANSWER B) Pale mucosa of the eyelids and lips" "The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses - CORRECT ANSWER D) Pupil responses" "In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant? A) Increased 10% in height B) 2 deciduous teeth C) Tripled the birth weight D) Head > chest circumference - CORRECT ANSWER C) Tripled the birth weight" "A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to A) 1Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes B) Ask the client what foods are acceptable or bad C) Encourage her to eat for healing and strength D) Schedule the dietitian to meet with the client as soon as possible - CORRECT ANSWER B) Ask the client what foods are acceptable or bad" "The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age? A) Cooing B) Imitation of sounds C) Throaty sounds D) Laughter - CORRECT ANSWER B) Imitation of sounds" "The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended? A) Seizures B) Withdrawal C) Craving D) Marked tolerance - CORRECT ANSWER B) Withdrawal" "Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner's injuries by A) Seeking medical help for the victim's injuries B) Minimizing the episode and underestimating the victim's injuries C) Contacting a close friend and asking for help D) Being very remorseful and assisting the victim with medical care - CORRECT ANSWER B) Minimizing the episode and underestimating the victim's injuries" "The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should A) Observe the child's behavior on at least 2 occasions B) Consult with the teacher about how to control impulsivity C) Compile a history of behavior patterns and developmental accomplishments D) Compare the child's behavior with classic signs and symptoms - CORRECT ANSWER C) Compile a history of behavior patterns and developmental accomplishments" "Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care? A) Measure head circumference B) Place in airborne isolation C) Provide passive range of motion D) Provide an over-the-crib protective top - CORRECT ANSWER A) Measure head circumference" "A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory results, the nurse would expect to find elevation in which of the following values? A) Blood urea nitrogen B) Acid phosphatase C) Bilirubin D) Sedimentation Rate - CORRECT ANSWER C) Bilirubin" "The nurse is discussing nutritional requirements with the parents of an 18 month-old child. Which of these statements about milk consumption is correct? A) May drink as much milk as desired B) Can have milk mixed with other foods C) Will benefit from fat-free cow's milk D) Should be limited to 3-4 cups of milk daily - CORRECT ANSWER D) Should be limited to 3-4 cups of milk daily" "To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) Apply suction for no more than 10 seconds B) Maintain sterile technique C) Lubricate 3 to 4 inches of the catheter tip D) Withdraw catheter in a circular motion - CORRECT ANSWER A) Apply suction for no more than 10 seconds" "An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) Administer the medication in 2 separate injections B) Give the medication in the dorsal gluteal site C) Call to get a smaller volume ordered D) Check with pharmacy for a liquid form of the medication skip - CORRECT ANSWER A) Administer the medication in 2 separate injections" "The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A) Enhance absorption of the medication B) Ensure that the entire dose of medication is given C) Provide more even distribution of the drug D) Prevent the drug from tissue irritation Skip - CORRECT ANSWER D) Prevent the drug from tissue irritation Skip" "A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) Diaphoresis with decreased urinary output B) Increased heart rate with increase respirations C) Improved respiratory status and increased urinary output D) Decreased chest pain and decreased blood pressure - CORRECT ANSWER C) Improved respiratory status and increased urinary output" "While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? A) "As you urinate more, you will need less medication to control fluid. "B) "You will have to take this medication for about a year." C) "The medication must be continued so the fluid problem is controlled. "D) "Please talk to your health care provider about medications and treatments." - CORRECT ANSWER C) "The medication must be continued so the fluid problem is controlled." "A client is being discharged with a prescription for chlorpromazine (Thorazine).Before leaving for home, which of these findings should the nurse teach the client to report? A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dsypnea, nasal congestion - CORRECT ANSWER B) Sore throat, fever" "A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? A. Cleanse the foot with soap and water and apply an antibiotic ointment B. Provide teaching about the need for a tetanus booster within the next 72 hours. C. have the mother check the child's temperature q4h for the next 24 hours D. transfer the child to the emergency department to receive a gamma globulin injection - CORRECT ANSWER A. Cleanse the foot with soap and water and apply an antibiotic ointment" "Which type of accidental poisoning would the nurse expect to occur in children under age 6? A) Oral ingestion B) Topical contact C) Inhalation D) Eye splashes - CORRECT ANSWER A) Oral ingestion" "A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client? A) Reading B) Checkers C) Cards D) Ping-pong - CORRECT ANSWER D) Ping-pong" "The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate? A) Widening pulse pressure B) Pleural friction rub C) Distended neck veins D) Bradycardia - CORRECT ANSWER C) Distended neck veins" "Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis? A) Assess for generalized edema B) Monitor for increased urinary output C) Encourage rest during hyperactive periods D) Note patterns of increased blood pressure - CORRECT ANSWER D) Note patterns of increased blood pressure" "The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate? A) Schedule the therapy thirty minutes after meals B) Teach the child not to cough during the treatment C) Confine the percussion to the rib cage area D) Place the child in a prone position for the therapy - CORRECT ANSWER C) Confine the percussion to the rib cage area" "Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs - CORRECT ANSWER A) Orthostatic hypotension is a common side effect" "A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation? A) Degeneration of the alveoli B) Chronic broncho constriction of the large airways C) Lung remodeling and permanent changes in lung function D) Frequent pneumonia - CORRECT ANSWER C) Lung remodeling and permanent changes in lung function" "A mother wants to switch her 9 month-old infant from an iron fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse? A) Change the baby to whole milk B) Add chocolate syrup to the bottle C) Continue with the present formula D) Offer fruit juice frequently - CORRECT ANSWER C) Continue with the present formula" "Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice? A) When a family member offers information about their loved one B) When the client threatens self-harm and harm to others C) When the health care provider decides the family has a right to know the client's diagnosis D) When a visitor insists that the visitor has been given permission by the client - CORRECT ANSWER B) When the client threatens self-harm and harm to others" "The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care? A) Monitor for hyperkalemia B) Place in protective isolation C) Precautions with position changes D) Administer diuretics as ordered - CORRECT ANSWER C) Precautions with position changes" "The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment? A) Activity intolerance caused by fatigue related to chronic tissue hypoxia B) Impaired mobility related to chronic obstructive pulmonary disease C) Self-care deficit caused by fatigue related to dyspnea D) Ineffective airway clearance related to increased bronchial secretions - CORRECT ANSWER A) Activity intolerance caused by fatigue related to chronic tissue hypoxia" "The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure? A) Standing and sitting B) In both arms C) After exercising D) Supine position - CORRECT ANSWER B) In both arms" "The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group? A) Aerobic exercise classes B) Transportation for shopping trips C) Reminiscence groups D) Regularly scheduled social activities - CORRECT ANSWER C) Reminiscence groups" "Post-procedure nursing interventions for electroconvulsive therapy include A) Applying hard restraints if seizure occurs B) Expecting client to sleep for 4 to 6 hours C) Remaining with client until oriented D) Expecting long-term memory loss - CORRECT ANSWER C) Remaining with client until oriented" "The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding? A) Stand on 1 foot B) Catch a ball C) Skip on alternate feet D) Ride a bicycle - CORRECT ANSWER A) Stand on 1 foot" "The mother of a 15 month-old child asks the nurse to explain her child's lab results and how they show her child has iron deficiency anemia. The nurse's best response is A) "Although the results are here, your doctor will explain them later. "B) "Your child has less red blood cells that carry oxygen. "C) "The blood cells that carry nutrients to the cells are too large." D) "There are not enough blood cells in your child's circulation." - CORRECT ANSWER B) "Your child has less red blood cells that carry oxygen."" "In a child with suspected coarctation of the aorta, the nurse would expect to find A) Strong pedal pulses B) Diminishing carotid pulses C) Normal femoral pulses D) Bounding pulses in the arms - CORRECT ANSWER D) Bounding pulses in the arms" "At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates A) Feelings of increasing anxiety related to paranoia B) Social isolation related to altered thought processes C) Sensory perceptual alteration related to withdrawal from environment D) Impaired verbal communication related to impaired judgment - CORRECT ANSWER B) Social isolation related to altered thought processes" "A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? A) Reverse B) Airborne C) Standard precautions D) Contact - CORRECT ANSWER D) Contact" "The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? A) "The treatment requires reapplication in 8 to 10 days." B) "Bedding and clothing can be boiled or steamed." C) Children are not to share hats, scarves and combs. D) Nit combs are necessary to comb out nits. - CORRECT ANSWER C) Children are not to share hats, scarves and combs." "During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? A) Wash hands thoroughly before and after client contact B) Wear gloves when in contact with body secretions C) Double glove when in contact with feces or vomitus D) Wear gloves when disposing of contaminated linens - CORRECT ANSWER A) Wash hands thoroughly before and after client contact" "A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes? A) Grilled chicken sandwich and skim milk B) Roast beef, mashed potatoes, and green beans C) Peanut butter sandwich, banana, and iced tea D) Barbecue beef, baked beans, and cole slaw - CORRECT ANSWER B) Roast beef, mashed potatoes, and green beans" "After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, "My husband told me to get treatment or he would divorce me. I don't believe I really need treatment but I don't want my husband to leave me." Which response by the nurse would assist the client? A) "In early recovery, it's quite common to have mixed feelings, but unmotivated people can't get well." B) "In early recovery, it's quite common to have mixed feelings, but I didn't know you had been pressured to come." C) "In early recovery it's quite common to have mixed feelings, perhaps it would be best to seek treatment on an out client bases. " D) " In early recovery, it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you." - CORRECT ANSWER D) " In early recovery, it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you."" "A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passes loose, watery stool. Which of these is a nursing priority? A) Hold the infant at frequent intervals. B) Assess for neonatal withdrawal syndrome C) Offer fluids to prevent dehydration D) Administer paregoric to stop diarrhea - CORRECT ANSWER B) Assess for neonatal withdrawal syndrome" "The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to A) Dehydration B) Diminished blood volume C) Decreased cardiac output D) Renal failure - CORRECT ANSWER C) Decreased cardiac output" "The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is A) Pain B) Impaired gas exchange C) Cardiac output altered: decreased D) Fluid volume excess - CORRECT ANSWER C) Cardiac output altered: decreased" "The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the health care provider? A) Lifts head from the prone position B) Rolls from abdomen to back C) Responds to parents' voices D) Falls forward when sitting - CORRECT ANSWER D) Falls forward when sitting" "A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other measure should the nurse implement? A) Have respiratory support equipment available B) Immediately place her in the seclusion room C) Assess the client for anxiety and agitation D) Administer PRN dose of IM antipsychotic medication - CORRECT ANSWER A) Have respiratory support equipment available" "The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first A) Assess the client's airway B) Call for help C) Establish that the client is unresponsive D) See if anyone saw the client fall - CORRECT ANSWER C) Establish that the client is unresponsive" "The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to A) Check for subcutaneous emphysema in the upper torso B) Reposition the client to a position of comfort C) Call the health care provider as soon as possible D) Check for any increase in the amount of thoracic drainage - CORRECT ANSWER A) Check for subcutaneous emphysema in the upper torso" "The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these demonstrates the normal pathway? A) AV node, SA node, Bundle of His, Purkinje fibers B) Purkinje fibers, SA node, AV node, Bundle of His C) Bundle of His, Purkinje fibers, SA node , AV node D) SA node, AV node, Bundle of His, Purkinje fibers - CORRECT ANSWER D) SA node, AV node, Bundle of His, Purkinje fibers" "When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first? A) Try to vigorously stimulate normal breathing B) Ask the RN to assess the vital signs C) Measure the pulse oximetry D) Continue to monitor respirations - CORRECT ANSWER D) Continue to monitor respirations" "When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because A) Normal patterns of behavior may be labeled as deviant, immoral, or insane B) The meaning of the client's behavior can be derived from conventional wisdom C) Personal values will guide the interaction between persons from 2 cultures D) The nurse should rely on her knowledge of different developmental mental stages - CORRECT ANSWER A) Normal patterns of behavior may be labeled as deviant, immoral, or insane" "The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client? A) Assign an RN to provide total care of the client B) Assign a nursing assistant to help the client with self-care activities C) Delegate complete care to an unlicensed assistive personnel D) Supervise a nursing assistant for skin care - CORRECT ANSWER D) Supervise a nursing assistant for skin care" "The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process? A) Assist a client post cerebral vascular accident to ambulate B) Feed a 2 year-old in balanced skeletal traction C) Care for a client with discharge orders D) Collect a sputum specimen for acid fast bacillus - CORRECT ANSWER C) Care for a client with discharge orders" "After working with a very demanding client, an unlicensed assistive personnel(UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond by saying A) "He has a lot of problems. You need to have patience with him. "B) "I will talk with him and try to figure out what to do." C) "He is scared and taking it out on you. Let's talk to figure out what to do." D) "Ignore him and get the rest of your work done. Someone else can take care of him forthe rest of the day." - CORRECT ANSWER C) "He is scared and taking it out on you. Let's talk to figure out what to do."" "A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements? A) I am sorry. Referral information can only be provided by the client's health care providers. B) "I can never give any information out by telephone. How do I know who you are?" C) Since this is a referral, I can give you this information. D) I need to get the client's written consent before I release any information to you. - CORRECT ANSWER D) I need to get the client's written consent before I release any information to you." "A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that A) A referral is needed to the psychiatrist who is to provide the client with answers B) The client has a right to know about the prescribed medications C) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications D) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects - CORRECT ANSWER B) The client has a right to know about the prescribed medications" "Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time? A) "Have the client sit on the side of the bed for at least 2 minutes before helping him stand." B) "If the client is dizzy on standing, ask him to take some deep breaths." C) "Assist the client to the bathroom at least twice on this shift." D) "After you assist him to the chair, let me know how he feels." - CORRECT ANSWER A) "Have the client sit on the side of the bed for at least 2 minutes before helping him stand."" "The nurse receives a report on an older adult client with middle stage dementia.What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client A) Has had a change in respiratory rate by an increase of 2 breaths B) Has had a change in heart rate by an increase of 10 beats C) Was minimally responsive to voice and touch D) Has had a blood pressure change by a drop in 8 mmHg systolic - CORRECT ANSWER C) Was minimally responsive to voice and touch" "A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is A) "I must document and report any information." B) "I can't make such a promise." C) "That depends on what you tell me." D) "I must report everything to the treatment team." - CORRECT ANSWER C) Was minimally responsive to voice and touch" "Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? A) Be with a client who self-administers insulin B) Cleanse and dress a small decubitus ulcer C) Monitor a client's response to passive range of motion exercises D) Apply and care for a client's rectal pouch - CORRECT ANSWER D) Apply and care for a client's rectal pouch" "A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first A) Focus on reality orientation to place and person B) Assist with the report of the client's complaint to the police C) Obtain more details of the client's claim of abuse D) Document the statement on the client's chart with a report to the manager - CORRECT ANSWER C) Obtain more details of the client's claim of abuse" "A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with A) A Dopamine drip IV with vital signs monitored every 5 minutes B) A myocardial infarction that is free from pain and dysrhythmias C) A tracheotomy of 24 hours in some respiratory distress D) A pacemaker inserted this morning with intermittent capture - CORRECT ANSWER B) A myocardial infarction that is free from pain and dysrhythmias" "An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions? A) "How long have you been a UAP and what units you have worked on?" B) "What type of care do you give on the surgical unit and what ages of clients?" C) "What is your comfort level in caring for children and at what ages?" D) "Have you reviewed the list of expected skills you might need on this unit?" - CORRECT ANSWER D) "Have you reviewed the list of expected skills you might need on this unit?"" "A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse's response should be to A) Ask to not be assigned to this client or to work on another unit B) Tell the client that such behavior is inappropriate C) Inform the client that hospital policy prohibits staff to date clients D) Discuss the boundaries of the therapeutic relationship with the client - CORRECT ANSWER D) Discuss the boundaries of the therapeutic relationship with the client" "In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize A) Learning relaxation techniques B) Limiting alcohol use C) Eating smaller meals D) Avoiding passive smoke - CORRECT ANSWER A) Learning relaxation techniques" "The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance? A) Arterial septal defect B) Patent ductus arteriosus C) Aortic stenosis D) Ventricular septal defect - CORRECT ANSWER D) Ventricular septal defect" "Clients with mitral stenosis would likely manifest findings associated with congestion in the A) Pulmonary circulation B) Descending aorta C) Superior vena cava D) Bundle of His - CORRECT ANSWER A) Pulmonary circulation" "The nurse is teaching a smoking cessation class and notices there are 2 pregnant women in the group. Which information is a priority for these women? A) Low tar cigarettes are less harmful during pregnancy B) There is a relationship between smoking and low birth weight C) The placenta serves as a barrier to nicotine D) Moderate smoking is effective in weight control - CORRECT ANSWER B) There is a relationship between smoking and low birth weight" "What is the best way for the nurse to accomplish a health history on a 14 year-old client? A) Have the mother present to verify information B) Allow an opportunity for the teen to express feelings C) Use the same type of language as the adolescent D) Focus the discussion of risk factors in the peer group - CORRECT ANSWER B) Allow an opportunity for the teen to express feelings" "What principle of HIV disease should the nurse keep in mind when planning care for a newborn who was infected in utero? A) The disease will incubate longer and progress more slowly in this infant B) The infant is very susceptible to infections C) Growth and development patterns will proceed at a normal rate D) Careful monitoring of renal function is indicated - CORRECT ANSWER B) The infant is very susceptible to infections" "While planning care for a preschool aged child, the nurse understands needs. Which of the following would be of the most concern to the nurse? A) Playing imaginatively B) Expressing shame C) Identifying with family D) Exploring the playroom - CORRECT ANSWER B) Expressing shame" "A client has been receiving lithium (Lithane) for the past two weeks for the treatment of bipolar illness. When planning client teaching, what is most important to emphasize to the client? A) Maintain a low sodium diet B) Take a diuretic with lithium C) Come in for evaluation of serum lithium levels every 1-3 months D) Have blood lithium levels drawn during the summer months - CORRECT ANSWER D) Have blood lithium levels drawn during the summer months" "While teaching a client about their medications, the client asks how long it will take before the effects of lithium take place. What is the best response of the nurse? A) Immediately B) Several days C) 2 weeks D) 1 month - CORRECT ANSWER C) 2 weeks" "The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include A) Pointing out inconsistencies in speech patterns to correct thought disorders B) Accepting client and the client's behavior unconditionally C) Encouraging dependency in order to develop ego controls D) Consistent limit-setting enforced 24 hours per day - CORRECT ANSWER D) Consistent limit-setting enforced 24 hours per day" "Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called A) Craving B) Crashing C) Outward bound D) Nodding out - CORRECT ANSWER B) Crashing" "The nurse asks a client with a history of alcoholism about the client's drinking behavior. The client states "I didn't hurt anyone. I just like to have a good time, and drinking helps me to relax." The client is using which defense mechanism? A) Denial B) Projection C) Intellectualization D) Rationalization - CORRECT ANSWER D) Rationalization" "One reason that domestic violence remains extensively undetected is A) Few battered victims seek medical care B) There is typically a series of minor, vague complaints C) Expenses due to police and court costs are prohibitive D) Very little knowledge is currently known about batterers and battering relationships - CORRECT ANSWER B) There is typically a series of minor, vague complaints" "A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find? A) S3 heart sound B) Thready pulse C) Flattened neck veins D) Hypoventilation - CORRECT ANSWER A) S3 heart sound" "An explosion has occurred at a high school for children with special needs and severe developmental delays. One of the students accompanied with a parent is seen at a community health center a day later. After the initial assessment the nurse concludes that the student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next? A) Help the student to identify a specific problem B) Ask the parent to identify the major problem C) Ask the student to think of different alternatives D) Examine with the parent a variety of options - CORRECT ANSWER B) Ask the parent to identify the major problem" "Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode? A) "I think all children should have their heads shaved. "B) "I have been restricted in thought and harmed." C) "I have powers to get you whatever you wish, no matter the cost. " D) "I think all of my contacts last week have attempted to poison me." - CORRECT ANSWER C) "I have powers to get you whatever you wish, no matter the cost."" "A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." The nurse would document this behavior as A) Perseveration B) Circumstantiality C) Neologisms D) Flight of ideas - CORRECT ANSWER D) Flight of ideas" "During the change-of-shift report the assigned nurse notes a Catholic client is scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of prejudice? A) "I wonder who is paying for this trip to the hospital? "B) "I think she needs to go to the city hospital. "C) "All those people indulge in large families! "D) "Doesn't she know there's such a thing as birth control?" - CORRECT ANSWER D) "Doesn't she know there's such a thing as birth control?"" "Which of these statements by the nurse reflects the best use of therapeutic interaction techniques? A) "You look upset. Would you like to talk about it? "B) "I'd like to know more about your family. Tell me about them." C) "I understand that you lost your partner. I don't think I could go on if that happened to me." D) "You look very sad. How long have you been this way?" - CORRECT ANSWER A) "You look upset. Would you like to talk about it?"" "A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first? A) Ask client if there are any old injuries also present B) Interview the client without the persons who came with the client C) Gain client's trust by not being hurried during the intake process D) Photograph the specific injuries in question - CORRECT ANSWER B) Interview the client without the persons who came with the client" "A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? A) "I cannot give this medication as it is written. I have no idea of what you mean." B) "Would you please clarify what you have written so I am sure I am reading it correctly?" C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful." D) "Please print in the future so I do not have to spend extra time attempting to read your writing." - CORRECT ANSWER B) "Would you please clarify what you have written so I am sure I am reading it correctly?"" "What is the most important consideration when teaching parents how to reduce risks in the home? A) Age and knowledge level of the parents B) Proximity to emergency services C) Number of children in the home D) Age of children in the home - CORRECT ANSWER D) Age of children in the home" "A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should A) Administer a placebo B) Encourage increased fluid intake C) Administer the prescribed analgesia D) Recommend relaxation exercises for pain control - CORRECT ANSWER C) Administer the prescribed analgesia" "While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention? A) Respiratory rate of 42 B) Lethargy for the past hour C) Apical pulse of 54 D) Coughing up copious secretions - CORRECT ANSWER A) Respiratory rate of 42" "A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings? A) Lethargy B) Heat intolerance C) Diarrhea D) Skin eruptions - CORRECT ANSWER A) Lethargy" "The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? A) "Do not worry. Epilepsy can be treated with medications." B) "The seizure may or may not mean your child has epilepsy." C) "Since this was the first convulsion, it may not happen again." D) "Long term treatment will prevent future seizures." - CORRECT ANSWER B) "The seizure may or may not mean your child has epilepsy."" "Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? A) A young adult with a history of Down's syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness - CORRECT ANSWER D) A preschooler with intermittent episodes of alertness" "The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C) Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings - CORRECT ANSWER D) Pale, thin arms and legs, uninterested in surroundings" "As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss - CORRECT ANSWER D) Hair loss" "While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degreesCelsius). The appropriate nursing intervention is to A) Call the health care provider immediately B) Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client's fluid intake - CORRECT ANSWER B) Administer acetaminophen as ordered as this is normal at this time" "A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be A) Cover the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Initiate intravenous therapy D) Administer pain medication - CORRECT ANSWER B) Assess for dyspnea or stridor" "Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A) I started my period and now my urine has turned bright red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn't hurt when I went. - CORRECT ANSWER D) I went to the bathroom and my urine looked very red and it didn't hurt when I went." "Which of these parents' comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? A) I noticed a little lump a little above the belly button. B) The baby seems hungry all the time. C) Mild vomiting that progressed to vomiting shooting across the room. D) Irritation and spitting up immediately after feedings. - CORRECT ANSWER C) Mild vomiting that progressed to vomiting shooting across the room." "The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings? A) Decreased cardiac output B) Tissue hypoxia C) Cerebral edema D) Reduced oxygen saturation - CORRECT ANSWER B) Tissue hypoxia" "The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet A) High in carbohydrates and proteins B) Low in carbohydrates and proteins C) High in carbohydrates, low in proteins D) Low in carbohydrates, high in proteins - CORRECT ANSWER A) High in carbohydrates and proteins" "A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago.During the nurse's initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? A) "I have a sharp pain in my chest when I take a breath. "B) "I have been coughing up foul-tasting, brown, thick sputum. " C) "I have been sweating all day. "D) "I feel hot off and on." - CORRECT ANSWER "B) "I have been coughing up foul-tasting, brown, thick sputum." "The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop B) Apical click C) Systolic murmur D) Split S2 - CORRECT ANSWER A) S3 ventricular gallop" "Which of these observations made by the nurse during an excretory urogram indicate a complicaton? A) The client complains of a salty taste in the mouth when the dye is injected B) The client's entire body turns a bright red color C) The client states "I have a feeling of getting warm." D) The client gags and complains " I am getting sick." - CORRECT ANSWER B) The client's entire body turns a bright red color" "A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest. "B) "The tube will remove excess air from your chest." C) "The tube controls the amount of air that enters your chest. " D) "The tube will seal the hole in your lung." - CORRECT ANSWER "B) "The tube will remove excess air from your chest."" "The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7.30 D) Serum potassium 6 mEq/L - CORRECT ANSWER D) Serum potassium 6 mEq/L" "The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms - CORRECT ANSWER C) Dyspnea" "The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? A) Breath sounds can be heard bilaterally B) Mist is visible in the T-Piece C) Pulse oximetry of 88 D) Client is unable to speak - CORRECT ANSWER C) Pulse oximetry of 88" "A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?A) Drowsiness B) Complaint of nausea C) Pulse rate of 92 D) Restlessness - CORRECT ANSWER D) Restlessness" "During the evaluation phase for a client, the nurse should focus on A) All finding of physical and psychosocial stressors of the client and in the family B) The client's status, progress toward goal achievement, and ongoing re-evaluation C) Setting short and long-term goals to insure continuity of care from hospital to home D) Select interventions that are measurable and achievable within selected timeframes - CORRECT ANSWER B) The client's status, progress toward goal achievement, and ongoing re-evaluation" "The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client's behavior most likely indicates A) Neologisms B) Dissociation C) Flight of ideas D) Word salad - CORRECT ANSWER C) Flight of ideas" "A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age? A) Jumping rope B) Tying shoelaces C) Riding a tricycle D) Playing hopscotch - CORRECT ANSWER C) Riding a tricycle" "A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is A) A transparent film dressing B) Wet dressing with debridement granules C) Wet to dry with hydrogen peroxide D) Moist saline dressing - CORRECT ANSWER D) Moist saline dressing" "The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!" What would be the most appropriate next action? A) Leave the room and return five minutes later and give the medicine B) Explain to the child that the medicine must be taken now C) Give the medication to the father and ask him to give it D) Mix the medication with ice cream or applesauce - CORRECT ANSWER A) Leave the room and return five minutes later and give the medicine" "A nurse is doing pre conceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome? A) "I understand that a glass of wine with dinner is healthy. "B) "Beer is not really hard alcohol, so I guess I can drink some. "C) "If I drink, my baby may be harmed before I know I am pregnant. " D) "Drinking with meals reduces the effects of alcohol." - CORRECT ANSWER "C) "If I drink, my baby may be harmed before I know I am pregnant." "A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? A) Increased blood pressure B) Increased heart rate C) Loss of pulse in the extremity D) Decreased urine output - CORRECT ANSWER C) Loss of pulse in the extremity" "A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago.He received 1000 mL of IV fluid. Which action would be most likely to help him void? A) Have him drink several glasses of water B) Crede' the bladder from the bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again - CORRECT ANSWER C) Assist him to stand by the side of the bed to void" "The nurse is caring for a client who requires a mechanical ventilator for breathing.The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A) Disconnect the client from the ventilator and use a manual resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator - CORRECT ANSWER B) Perform a quick assessment of the client's condition" "The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? A) "I can't lie in 1 position for more than thirty minutes. "B) "I am allergic to shrimp." C) "I suffer from claustrophobia. "D) "I developed a severe headache after a spinal tap." - CORRECT ANSWER "B) "I am allergic to shrimp."" "The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube - CORRECT ANSWER A) Hold the tube feeding and notify the provider" "A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences: A. Bradycardia and constipation B. Lethargy and lack of appetite C. Muscle cramping and dry, flushed skin D. Palpitations and shortness of breath - CORRECT ANSWER D. Palpitations and shortness of breath" "A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? - CORRECT ANSWER Obtain a list of medications taken for cardiac history" "The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) - CORRECT ANSWER A. Fluid shifts from intravascular to interstitial area due to decreased serum protein B. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen C. Increased circulating aldosterone levels that increase sodium and water retention" "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) - CORRECT ANSWER Murmur" "A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound? A) Transparent dressing B) Dry sterile dressing with antibiotic ointment C) Wet to dry dressing D) Occlusive moist dressing - CORRECT ANSWER D) Occlusive moist dressing" "A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child? A) Cartoon stickers B) Large wooden puzzle C) Blunt scissors and paper D) Beach ball - CORRECT ANSWER B) Large wooden puzzle" "A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the A) Yang, the positive force that represents light, warmth, and fullness B) Yin, the negative force that represents darkness, cold, and emptiness C) Use of improper hot foods, herbs and plants D) A failure to keep life in balance with nature and others - CORRECT ANSWER B) Yin, the negative force that represents darkness, cold, and emptiness" "A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response? A) "There is a probability of life-long complications." B) "Cystic fibrosis results in nutritional concerns that can be dealt with." C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis." D) "You will work with a team of experts and also have access to a support group that the family can attend." - CORRECT ANSWER C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."" "The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? A) Three apricots B) Medium banana C) Naval orange D) Baked potato - CORRECT ANSWER D) Baked potato" "An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? A) Add a thickening agent to the fluids B) Check the client's gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids - CORRECT ANSWER B) Check the client's gag reflex" "The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? A) Place client in the wheelchair for four hours each day B) Pad the bony prominence C) Reposition every two hours D) Massage reddened bony prominence - CORRECT ANSWER C) Reposition every two hours" "A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic client - CORRECT ANSWER C) A client who had 3 incontinent diarrhea stools" "Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? A) Obtain a complete blood count B) Obtain a health and dietary history C) Refer to a provider for a physical examination D) Measure height and weight - CORRECT ANSWER B) Obtain a health and dietary history" "After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents - CORRECT ANSWER A) Abdominal x-ray" "A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client?A) Allow the client to melt ice chips in the mouth B) Provide mints to freshen the breath C) Perform frequent oral care with a tooth sponge D) Swab the mouth with glycerin swabs - CORRECT ANSWER C) Perform frequent oral care with a tooth sponge" "The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to A) Exercise doing weight bearing activities B) Exercise to reduce weight C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones - CORRECT ANSWER A) Exercise doing weight bearing activities" "The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? A) Cheese sandwich with a glass of 2% milk B) Sliced turkey sandwich and canned pineapple C) Cheeseburger and baked potato D) Mushroom pizza and ice cream - CORRECT ANSWER B) Sliced turkey sandwich and canned pineapple" "Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? A) All 4 side rails up, wheels locked, bed closest to door B) Lower side rails up, bed facing doorway C) Knees bent, head slightly elevated, bed in lowest position D) Bed in lowest position, wheels locked, place bed against wall - CORRECT ANSWER D) Bed in lowest position, wheels locked, place bed against wall" "The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group? A) Bulimia B) Anorexia C) Obesity D) Malnutrition - CORRECT ANSWER C) Obesity" "At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should A) Invite the client to join the exercise group B) Tell the client you will call someone to come for her C) Give the client simple information about what she will be doing D) Firmly direct the client to her assigned group activity - CORRECT ANSWER C) Give the client simple information about what she will be doing" "A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse? A) "The violence is temporarily caused by unusual circumstances, don't stop hoping for a change. "B) "Perhaps, if you understood the need to abuse, you could stop the violence. "C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?" D) "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do." - CORRECT ANSWER D) "Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do."" "A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0- to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to A) Ask the client about the refusal of certain pain medications B) Talk with the client's family about the situation C) Report the situation to the health care provider D) Document the situation in the notes - CORRECT ANSWER A) Ask the client about the refusal of certain pain medications" "What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? A) Presence of blood in stools B) Oozing liquid stool C) Continuous rumbling flatulence D) Absence of bowel movements - CORRECT ANSWER B) Oozing liquid stool" "A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to A) Have the client identify coping methods B) Get the description of the location and intensity of the pain C) Accept the client's report of pain D) Determine the client's status of pain - CORRECT ANSWER C) Accept the client's report of pain" "An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be A) Assess the severity and location of the pain B) Obtain an order for an analgesic C) Reassure him that this is not unusual for his age D) Encourage him to increase his activity - CORRECT ANSWER A) Assess the severity and location of the pain" "A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: A) Visitors must wear a mask and a gown B) There are no special requirements for visitors of clients on contact precautions C) Visitors should wash their hands before and after touching the client D) Visitors