HESI Exit Exam 5 Graded A+ 2025

1. An adolescent male with severe acne recently started treatment with isotretinoin, a form of vitamin A. During a follow-up clinic appointment, which assessment is most important for the PN to complete? Ask about occurrence and frequency of nosebleeds. 2. The PN is caring for a client who has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. What is most important to reinforce in this client plan of care? B. Interventions to decrease emotional stress. 3. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the PN, who is taking the client the clients vital signs. What action should the PN implement? Reinforce the needs for extra rest periods and plenty of sleep. 4. The PN is completing a focused assessment of a client with acute hepatitis A. The client reports a constant sense of fatigue. How should the PN respond? Affirm the importance of rest to promote liver healing. 5. When the PN plans daily care for a group of clients, which client should the PN see first due to the risk of complication? An older client with a stroke who is febrile and confused. 6. Which foot care instructions is most important for the PN to reinforce that minimizes a long- term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)? Report any foot injury or sore that does not readily heal. 7. During a clinic visit for a sore throat a client’s basal metabolic panel reveals a serum potassium of 3.0 meq/L. Which action should the PN recommend to the client based on this finding? Increase intake of dried peached and apricots. 8. A client with a fractured left hip fracture is in Bucks's traction. The PN should expect the client to exhibit which outcome? The left foot is warm to touch with a palpable dorsalis pedis pulse. 9. When entering the room of an older female resident of a long-term care facility, the PN finds one of the male residents in bed with her. What action should the PN take? Quietly escort the male client back to his room. 10. Prior to giving digoxin, the PN assesses that a 2-month-old infants heart rate is 120 beats/min. Based on this finding what action should the PN take? Give the medication and document the heart rate. 11. A resident of a long-term care facility who has a drainage stage 2 pressure ulcer receives a prescription for sterile, warm, moist compress q12 hours for 20 minutes to the site. What precautions should the PN take when performing this procedure? Select all that apply. -remove soiled dressings with procedure gloved and don sterile gloves for moist dressing application. -place 4x4 gauze sponges on the pressure ulcer and pour warmed water on the dressed site. -pour warmed sterile solution to an open sterile dressing tray that contained sterile gauze pads. 12. A male client who is diagnosed with schizophrenia is taking an antipsychotic medication and calls the psychiatric clinic. The client tells the PN that he is achy and stiff, has a temperature of 103.4 F and is sweating. How should the PN respond to this client? Direct the client to obtain immediate transportation to the emergency center. 13. The Glasgow coma scale is being used to monitor a client in the critical care unit. The scale is used to evaluate what client status? Level of consciousness. 14. A client is diagnosed with hyperthyroidism. Which symptoms should the PN expect this client to exhibit? Muscle cramping and dry, flushed skin. 15. The PN administers an antibiotic to a client with a respiratory tract infection...evaluate the medications effectiveness, which laboratory values should the PN monitor? Select all that apply -Sputum culture and sensitivity -white blood cell count 16. To obtain an estimate of a client’s systolic blood pressure, what action should the PN take first? Palpate the client's brachial pulse. 17. A client reports feeling numbness and tingling in extremities. What action should the PN implement? Review the client's serum electrolyte levels. 18. Immediately after birth, which nursing intervention has the highest priority for the newborn infant? Preventing heat loss and neonatal cold stress. 19. The PN overhears a female client with Cushing’s syndrome tell her family in a... Very loud and angry voice to leave her room and not come back. The response by the PN is bead on recognizing which common manifestation of the syndrome? Mood alterations. 20. A 0800 a client’s apical pulse rate is 98 beats/minute> Four hours later the apical pulse rate is 54 beats/minute. What action should the PN take next? Determine the level of consciousness. 21. After three weeks of antibiotic therapy, a child who weighs 55 pounds develops painful oral lesions, so the heal care provider prescribes acyclovir (Zovirax) 20 mg/kg daily. How many mg should the PN administer to this child? 500 22. The PN is assisting a client to the bathroom after right cataract extraction. The client has an eye shield over the right eye. How should the PN asset the client during ambulation? Stand in front of the client and lead the client forward to the bathroom. 23. Which client information is most important for the PN to consider when providing instructions to the UAP about providing morning care to a postoperative client? Urinary output of 50 ml/hour. 24. A male client who was admitted with gangrene of the right lower extremity is confused and his wife refuses to sign the operative permit for an above the knee amputation. What action should the PN take first? Encourage the client's wife to express concerns about making the decision. 25. After report, the PN receives the laboratory values for four clients. Which client requires the PN immediate intervention? Client who is trembling and has a glucose level of 50 mg/dl. 26. Based on the nursing diagnosis of "risk for infection" which intervention should the PN implement when providing care for an elderly client with urinary incontinence? Maintain standard precautions. 27. During recovery after the delivery of a normal infant a client is receiving...ringers 1000 ml with oxytocin 20 units. The PN should evaluate the client for which therapeutic response? Stimulation of uterine contractions. 28. The spouse of a hospitalized client asks the PN for acetaminophen for a tension headache.Which action should the PN take? Explain that medication can only be provided to clients. 29. A 5-year-old child is admitted with full thickness burns over 30% of the total body surface areas (TBSA). After fluid replacement therapy is initiated, which finding should the PN use to evaluate the effectiveness of the therapy? Urine output. 30. When the PN attempts to assist an 18-year-old female client with mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and yells at the PN "get out of here! I’ll get up when I'm ready!" which response is best for the PN to make? I know you feel angry about the pain of ambulation, but this is a necessary part of getting well. 31. A client with hypertension complains of a persistent dry cough. The PN should tell the client that this is a common side effect of which daily medication? C. Quinapril (Accupril). 32. The PN enters the room of a client who is disoriented and has a wrist restraint secured as seen in the picture what action should the PN take? Photo is of hospital bed and restraint Is on the bed frame in a bow tie. Use a full knot to secure the restraint tied. 33. The PN views the mid-line episiotomy of a client who reports pain in her stitches. What action should the PN take first? Observe suture line for separation and hematoma formation. 34. A new mother asks the PN about an area of swelling on her baby head that lies across the suture line near the posterior fontanel. How should the PN respond? Caput succedaneum will be absorbed and cause no problems. 35. The PN obtains a finger stick glucose for a client with type 1 diabetes mellitus who is conscious and demonstrating hand tremors and shaking. The PN reports the clients result of 55 mg/dl to the nurse. What action should the PN implement next? Provide the client of glass of milk and crackers. 36. A client who is primigravida at term comes to the prenatal clinic and tells the PN that she is having contractions every 5 minutes. The PN monitors the client for 1 hour using an external fetal monitor and determines that the clients’ contractions are 7 to 15 minutes apart lasting 20-30 seconds with mild intensity by palpation. What action should the PN take? Send the client home and instruct her to call the clinic when her contractions occur every 5 minutes apart for one hour. 37. Which product should the PN provide to ensure effective oral care for a client undergoing chemotherapy? Soft-bristled toothbrush. 38. The PN plans to evaluate an adult’s response to a prescription for colchicine. Last week the client was seen in the clinic for pain in the great left toe, which was the result of an acute attack of gout. Which data should the PN obtain to evaluate the therapeutic effectiveness of this medication? Pain scale level during walking. 39. The PN is caring for a client who was recently diagnosed with hepatitis B virus (HBV). The PN observes that the client’s urine is the color of dark tea. What action should the PN take? Encourage increased oral fluid intake. 40. In administering nystatin suspension to the gums of an infant with a candida infection, which approach should the PN take? Use a gloved finger to rub the suspension over the infected area. 41. While the PN and UAP are turning a client with an abdominal incision, the client’s incision eviscerates. Which task is best for the PN to assign to the UAP? Gather supplies. 42. A client develops generalized edema associated with chronic kidney disease (CKD). The PN understands the formation of the edema is the result of which physiological process? Plasma protein resulting in decreased oncotic pressure within the vessels. 43. The PN and UAP are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the PN implement? Demonstrate to the UAP how to approach the client from the client's left side. 44. An older adult female is admitted with syncope and laboratory findings indicate that her hemoglobin is 8.0 grams /dl. She has a recent history of headaches and frequent falls. Admission prescription orders include continuation of all home medications. Which medication should the PN withhold until consulting with the charge nurse? Aspirin. 45. The PN is planning care for a client who has generalized tonic colonic seizures and is vomiting and having frequent diarrhea stools to reduce the risk of injury to this client which nursing measurements should the PN implement? Axillary temperatures and padded side rails. 46. When assessing an adult male who present at the community health clinic with a history of hypertension the nurse notes that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflux disease and depression. Which interventions is most important for the PN to implement? C. Review the client' use of over the counter (OTC) medications. 47. A client with Alzheimer’s disease (AD) is receiving trazadone (Desyrel) a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client’s mood and sleep patterns are improved but there is no change in cognitive ability. How should the nurse respond to this information? Confirm that the desired effect of medication has been achieved. 48. 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 client’s refusal? Emphasize the importance of active foot flexion. 49. After applying alcohol-based hand rub to the palms of the hand and rubbing paps together what action should the PN take next? Place hands on top of each other and interlace fingers. 50. A new mother is bottle feeding instead of breastfeeding the PN should instruct the to most effective way to deal with breast engorgement and discomfort is to? Wear supportive bra at all times. 51. Because of staffing shortages the charge nurse assigns a PN to perform a skill which the PN is not yet certified to perform what is the best response by the PN? I am uncomfortable performing a skill which I am not certified. 52. A client recovering from a stroke is learning how to use a cane. How should it be placed? On the stronger side of body. 53. A client with 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. 54. While performing the apical pulse of an adult male client the PN 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. 55. A client with type 2 diabetes becomes unresponsive and says I'm not feeling right which action should the PN take? Give 4 ounces of apple juice. 56. 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 areolar tissue of the nipple is in the infant’s mouth. 57. A client with irritable bowel syndrome is receiving dicyclomine an anticholinergic drug? Provide oral care. 58. The PN is caring for a client in bucks tract what is the priority goal for the client in traction? Maintain straight body alignment. 59. What site should the PN use when administering RHO D? Deltoid. 60. Client with Huntington’s disease starts jerking around while the family is there what should the PN do? Offer emotional support to family. 61. When should a person use additional birth control precautions? When taking antibiotics for an infection. 62. 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. 63. Client voiding small amounts every 24 hours. The catheterized volume determines the need to reinsert the indwelling catheter. 64. Based on the principle of asepsis the PN should consider which situation to be sterile? An open Foley catheter kit set up on a table at the PN waist level. 65. A client with small bowel obstruction is experiencing frequent vomiting which instructions are most important for the PN to provide to the UAP who is completing morning care for this client? Measure all emesis accurately. 66. Single mother of a child with head injury comes crying to the clinic what should the PN tell her? This must seem overwhelming to you right now. 67. On admission to the medical unit a client who is homeless and has a history of HIV with persistent cough? Erythema and indurations of 5mm at site. 68. When preparing to administer medications to an older resident the PN notices that several medications that were supposed to be administered during the previous shift have not been entered as given in the computer. What action should the PN take? Contact the medication nurse to clarify the findings. 69. The hearing of ringing in the ears what medication should be reported to the health provider? Gentamicin. 70. 28-year-old client is in active labor and complains of a cramp in her leg. What intervention should the PN implement? Extend the leg and flex the foot. 71. A client is admitted for observation after experiencing a TIA High risk for injury. 72. Following discharge teaching, a male client with duodenal ulcer tells the nurse he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow- up action by the nurse? Review with the client the need to avoid foods that are rich in milk and cream. 73. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? Stroke secondary to hemorrhage. 74. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. 4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up? Describes life without purpose. 75. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan? Further evaluation involving surgery may be needed. 76. A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? Teach tracheal suctioning techniques. 77. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement? Document the assessment data. 78. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs? Respiratory apnea of 30 seconds. 79. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? Check the client for lacerations or fractures. 80. At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? Inform the anesthesia care provider. 81. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first? Listen with the bell at the same location. 82. A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? Medicare. 83. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? Toasted wheat bread and jelly. 84. Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? "I have a headache that gets worse when I sit up" 85. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? Obtain a clean catch mid-stream specimen. 86. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child? Foods sweetened with aspartame. 87. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? Direct the nurse to continue the surgical hand scrub for a 5 minute duration. 88. Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis? Bagel with jelly and skim milk. 89. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied. 90. 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? Cleanse the foot with soap and water and apply an antibiotic ointment. 91. The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement." What instruction should the nurse provide? Stop using the ointment and encourage complete drying of the feet and wearing clean socks. 92. 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: Palpitations and shortness of breath. 93. 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? Obtain a list of medications taken for cardiac history. 94. The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) 75 ml/hour. 95. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply). -Fluid shifts from intravascular to interstitial area due to decreased serum protein -Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen -Increased circulating aldosterone levels that increase sodium and water retention 96. 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. 97. 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 ml 98. The 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. 99. 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. 100. 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. 101. 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? 102. 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. 103. 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. 104. 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. 105. 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. 106. The client with which type of wound is most likely to need immediate intervention by the nurse? Laceration. 107. 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. 108. 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. 109. 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 gallbladder is normal. 110. 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? Inform her that some antianxiety medications are safe to take while breastfeeding. 111. 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. 112. 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? The additive effect of multiple medications has caused the blood pressure to drop too low. 113. Which client is at the greatest risk for developing delirium? An adult client who cannot sleep due to constant pain. 114. 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. 115. Which location should the nurse choose as the best for beginning a screening program for hypothyroidism? A business and professional women's group. 116. 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. 117. 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? Serum calcium. 118. What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? The technique is intended to maintain straight spinal alignment. 119. 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. 120. Which action should the school nurse take first when conducting a screening for scoliosis? Inspect for symmetrical shoulder height. 121. 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. 122. 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. 123. 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. 124. 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 125. A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement? Negative pressure environment. 126. A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child? Sitting up and leaning forward. 127. 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. 128. 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. 129. 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. 130. 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. 131. 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. 132. 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. 133. 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. 134. 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." 135. 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. 136. 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. 137. 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. 138. 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. 139. 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. 140. 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. 141. In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor? Glucose. 142. Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client? Use two forms of contraception while taking this drug. 143. 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. 144. 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). 145. 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. 146. 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. 147. 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. 148. 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. 149. 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 Naloxone IV. 150. 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. 151. 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. An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the uaps behavior? (Place the action in order from first on top to last on bottom.) -Note date and time of the behavior. -Discuss the issue privately with the UAP. -Plan for scheduled break times. -Evaluate the UAP for signs of improvement. 153. A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer's at 100 ml/H. Which finding is most important for the nurse to report to the healthcare provider? Serum potassium level of 3.1 meq/L or mmol/L (SI). 154. Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms? Eosinophils. 155. The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat? Yogurt and/or buttermilk. 156. Several months after a foot injury, and adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will "finally go away." How should the nurse respond? Assist the client in developing a goal of managing the pain. 157. One day following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of "a tingly sensation" in his left foot. The nurse determines the client's left pedal pulses are diminished. Based on these finding, what is the client's greatest risk? Neurovascular and circulation compromise related to compartment syndrome. 158. The nurse is completing a head to be assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse? Clear fluid leaking from the nose. 159. A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff's sign). Which pathophysiological mechanism supports this response? Temporary vasodilation. 160. While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement? Promptly remove the arterial catheter from the radial artery. 161. (Alternative format) donning gloves. Second gloves. 162. A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful. Research indicates that mirror therapy is effective in reducing phantom limb pain. 162. The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a post-op complication? Poor feeding and vomiting, leakage of CSF from the incisional site, abdominal distention. 163. The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take. Remove the heating pads and place a soft blanket over the client's leg and feet. 164. An adult client with severe depression was admitted to the psych unit yesterday evening. Although the client ran one year ago, his spouse states that the client no longer runs, bur sits and watches television most of the day. Which is most important for the nurse to include in this client's plan of care for today. Assist client in identifying goals for the day. 165. A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? Current diagnosis of Hep B. 166. A school nurse assessing a preschool girl with hair intentionally placed over bald patches and redness. Notified child services. 167. Providing hygiene care for a patient reports feeling dizzy, blood pressure is like 84/64, what intervention would you do. Provide a bed bath. 168. Patient comes to clinic two weeks after a hurricane reports diarrhea. Contaminated water. 169. Client who was in South Africa, presenting with flu like symptoms. Initiate airborne precautions. 170. Lymph nodes in an 18-month-old. Preauriculer tender, nonmovable. 171. Patient with cataract removal, feels nauseous post-op. Provide IV Zofran. 172. Patient with respiratory infection, monitoring antibiotic therapy, select all that apply. -sputum culture -white blood cell count 173. (Alternative format) JP drain. Empty drain. 174. (Alternative format) lung sound. High pitched wheezing. 175. Math calculations. Micrograms to milligrams dosage mcg - mg = divide by 1,000. 176. Patient with mandible injury, jaw shut. Wire cutters. 177. Patient had bladder irrigation, rn observes it, what is the next step. Milk the tubing. 178. Older adult suffering with constipation, select all that apply: -use of diet -immobility -use of laxatives -use of medications 179. Osteomyelitis is: Inflammation infection. 180. Patient believes she is in labor; how can you verify. Some type of test (amniotic fluid). 181. Pediatric patient, which is most concerning with 9-month-old infant gaining weight. Drinking cow’s milk. 182. Patient diagnosed with breast cancer, cells abnormal. Encourage Pt to express fears and concerns. 183. Patient with personality disorder, complaining about night staff, saying "you're my favorite nurse", patient being discharge that day, what do you do. Acknowledge discharge. 184. Histamine antagonist. Inhibits. 185. (Alternative format). Click blood glucose 62. 186. (Alternative format) chest tube. 850 - put between 800 and 900. 187. A female nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administrator approaches the charge nurse with the impaired nurse request, which action is best for the charge nurse to take. Allow the impaired nurse to return to work and monitor medication. 188. Nurses working on a surgical unit are concerned about the physicians treatment of clients during invasive procedures, such as dressing changes and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client's response. To resolve this problem, what actions should the nurses take. (Arrange from the first action on the top of the list on the bottom): 1. Talk to the physician as a group in a non-confrontational manner. 2. Document concerns and report them to the charge nurse 3. Submit a written report to the director of nursing 4. Contact the hospital's chief of medical services 5. File a formal complaint with the state medical board 189. The nurse identifies an electrolyte imbalance, an elevated pulse rate, and elevated BP for a client with chronic kidney disease, which is the most important action for the nurse to take. Auscultate for irregular heart rate. 190. The nurse is triaging clients in an urgent care clinic, the client with which symptoms should be referred to the health care provider. Headache, photophobia, nuchal rigidity. 191. A male client who was admitted with an acute MI receives a cardiac diet with sodium restriction and complains that his hamburger is flavorless, which condiment should the nurse offer. Fresh horseradish. 192. A client arrives in the emergency center with a blood alcohol level of 500 mg/dl, when transferred to the observation unit, the client becomes demanding, aggressive, and shouts at the staff, which assessments findings is most important for the nurse to identify in the first 24 hours. Agitation and threats to harms staff. 193. Following an open reduction of the tibia, the nurse notes bleeding on the client's cast, which action should the nurse implement. Outline the area with ink and check it every 15 minutes to see if the area has increased. 194. A client is admitted to the surgical unit with symptoms of a possible intestinal obstruction, when preparing to insert a nasogastric (NG) tube, which intervention should the nurse implement. Elevate the head of the bed 60 to 90 degrees. 195. The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor, what intervention should the nurse implement immediately. Elevate the presenting part off the cord. 196. A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy, the client has saline lock and is sleeping quietly without any restlessness, the nurse caring for the client is not certified in chemotherapy administration, what action should the nurse take. Administer the ondasentron (Zofran) after flushing the saline lock with saline. 197. Pulmonary embolism. Two questions on PE: Restlessness, anxiety, lethargic 198. Patient has redness. Document the finding as healing. 199. During shift report, the central electrocardiogram (EKG) monitoring system alarms, which client alarm should the nurse investigate first. Respiratory apnea of 30 seconds. 200. Patient with dietary restrictions, which food, select all that apply. -toast and jelly, etc. -not select bagel and cream cheese, not select 2% milk 201. Action for the RN to find in a child with sclerosis. Asymmetric shoulder height. 202. 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. 203. Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia, what information is most important for the nurse to provide to this client. Use two forms of contraception while taking this drug. 204. 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). 205. Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy, twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours, what pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider. Oliguria signals tubular necrosis related to hypoperfusion. 206. An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue, what action should the nurse take in response to this finding. Document the ongoing wound healing. 207. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan, select all that apply. Recognize signs and symptoms of hypoglycemia, report persist polyuria to the healthcare provider, take Glucophage with the morning and evening meal. 208. Infant receiving digoxin the nurse should be alert to which finding as a sign of toxicity.