HESI EXIT RN EXAM QUESTION AND ANSWERS

HESI EXIT RN EXAM QUESTION AND ANSWERS (750 QUESTIONS AND ANSWERS, RATIONALE OF EACH ANSWER INCLUDED) 1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the 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? a. Remind the client that it is also important to switch to decaffeinated coffee and tea. b. Suggest that the client also plan to eat frequent small meals to reduce discomfort d. Reinforce this teaching by asking the client to list a dairy food that he might select. 2. 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 med- ication 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? a. Blindness secondary to cataracts b. Acute kidney injury due to glomerular damage c. Stroke secondary to hemorrhage d. Heart block due to myocardial damage 3. The nurse observes an unlicensed assistive personnel (UAP) posi- tioning 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? a. Ensure that the UAP has placed the pillows effectively to protect the client. b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. a. Assume responsibility for placing the pillows while the UAP completes another task. b. Ask the UAP to use some of the pillows to prop the client in a side lying position. 4. An adolescent with major depressive disorder has been taking du- loxetine (Cymbalta) for the past 12 days. Which assessment find- ing requires immediate follow-up? a. Describes life without purpose b. Complains of nausea and loss of appetite c. States is often fatigued and drowsy d. Exhibits an increase in sweating. disorder. B, C and D are side effects 5. A 60-year-old female client with a positive family history of ovar- ian cancer has developed an abdominal mass and is being evaluat- ed for possible ovarian cancer. Her Papanicolau (Pap) smear re- sults are negative. What information should the nurse include in the client’s teaching plan? a. Further evaluation involving surgery may be needed b. A pelvic exam is also needed before cancer is ruled out c. Pap smear evaluation should be continued every six month d. One additional negative pap smear in six months is needed. Rationale: An abdominal mass in a client with a family history for ovarian cancer should be evaluated carefully 6. A client who recently underwear a tracheostomy is being pre- pared for discharge to home. Which instructions is most impor- tant for the nurse to include in the discharge plan? a. Explain how to use communication tools. b. c- Encourage self-care and independence. d- Demonstrate how to clean tracheostomy site. 7. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely dur- ing inspiration and the client’s respiratory rate is 14 breaths / minute. What action should the nurse implement? a. Encourage the client to take deep breaths b. Remove the mask to deflate the bag c. Increase the liter flow of oxygen d. Document the assessment data 8. During a home visit, the nurse observed an elderly client with di- abetes slip and fall. What action should the nurse take first? a. Give the client 4 ounces of orange juice b. Call 911 to summon emergency assistance c. Check the client for lacerations or fractures d. Asses clients blood sugar level 9. 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? a. Ensure preoperative lab results are available b. Start prescribed IV with lactated Ringer’s c. d- Contact the client’s obstetrician. 10. After placing a stethoscope as seen in the picture, the nurse auscul- tates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first? a. Side the stethoscope across the sternum. b. Move the stethoscope to the mitral site c. d- Observe the cardiac telemetry monitor 11.A 66-year-old woman is retiring and will no longer have a health in- surance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? a. Woman, Infant, and Children program b. Medicaid c. Medicare d. Consolidated Omnibus Budget Reconciliation Act provision. Rationale: Title XVII of the social security Act of 1965 created 12.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? a. Fruit-flavored yogurt. b. Cheese and crackers. c. Cold cereal with skim milk. d. Toasted wheat bread and jelly 13. Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? a. “I am having pain in my lower back when I move my legs” b. “My throat hurts when I swallow” c. “I feel sick to my stomach and am going to throw up” d. I have a headache that gets worse when I sit up” 14. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? a. Auscultate for renal bruits b. c- Use a dipstick to measure for urinary ketone d- Begin to strain the client’s urine. pre- scribed. 15. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child’s dietary re- strictions. Which foods are contraindicated for this child? a. Wheat products b. c- High fat foods d- High calories foods. 16. 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? a. Ask a more experience nurse to perform that scrub since it is the first time of the day b. Validate the nurse is implementing the OR policy for surgical hand scrub c. Inform the nurse that hand scrubs should be 3 minutes between cases. d. 17. Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary management of osteoporosis? a. Egg whites, toast and coffee. b. Bran muffin, mixed fruits, and orange juice. c. Granola and grapefruit juice d. Bagel with jelly and skim milk. 18. 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)? a. A 34-year -old admitted today after an emergency appendendectomy who has a peripheral intravenous catheter and a Foley catheter. b. A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance fol- lowing a race. c. A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline-locked peripheral intravenous catheter. d. - 19. Z a. 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 20. The mother of an adolescent tells the clinic nurse, “My son has ath- lete’s foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement.” What instruction should the nurse provide? a. Antibiotics take two weeks to become effective against infections such as athlete’s foot. b. Continue using the ointment for a full week, even after the symptoms disappear. c. Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration. d. oint- ments are not useful. 21.A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is pre- scribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences b- Bradycardia and constipation c. Lethargy and lack of appetite d. Muscle cramping and dry, flushed skin 22.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? a. Determine the client’s level of orientation and cognition b. Assess distal pulses and signs of peripheral edema c. d- Ask the client about exposure to environmental heat. pre- senting clinical picture. 23. 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.) a- 75 Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour 24. The pathophysiological mechanisms are responsible for ascites relat- ed to liver failure? (Select all that apply) a. Bleeding that results from a decreased production of the body’s clotting factors b. Fluid shifts from intravascular to interstitial area due to de- creased serum protein c. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen d. Increased circulating aldosterone levels that increase sodium and wa- ter retention e. Decreased absorption of fatty acids in the duodenum leading to abdominal distention. Rationale: Pressure increases in the portal circulation © when venous return from the upper GI tract cannot flow freely into sclerosed liver, which cause a pressure gradient to further Increase fluid shifts into the abdomen. 25. The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) a. S1 S2 b. S1 S2 S3 c. Murmur d. Pericardial friction rub. Rationale: A murmur is auscultated as a swishing sound that is asso- ciated with the blood turbulence created by the heart or valvular de- fect. B is associate with Heart Failure. 26. The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruc- tion 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) a- 0.4 Rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml 27. 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? a- Auscultate the client's bowel sounds b- Observe for edema around the ankles c. Measure the client’s capillary glucose level d. Count the apical and radial pulses simultaneously Rationale: hydromorphone is a potent opioid analgesic that slows peri- stalsis and frequently causes constipation, so it is most important to Aus- cultate the client's bowel sounds 28.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 breath- ing, and she asks the nurse to document this in her medical record. What action should the nurse implement? 29.A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new pre- scription to change the feeding to half strength. What intervention should the nurse implement? a. b. Continue the full strength feeding after decreasing the rate of infusion to 25 ml/hr. c. Maintain the present feeding until diarrhea subsides and the begin the next new prescription. d. Withhold any further feeding until clarifying the prescription with healthcare provides. 30.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? a. “Is there a history of female baldness in your family?” b. “Are you under any unusual stress at home or work?” c. “Do you work with hazardous chemicals?” d. “Have you noticed any changes in your fingernails?” 31. 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? a. Bruises on arms and legs b. Round and tight abdomen c. Pitting edema in lower legs d. Capillary refill of 8 seconds 32. After the nurse witnesses a preoperative client sign the surgical con- sent 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) a. The client voluntarily grants permission for the procedure to be done b. The surgeon has explained to the client why the surgery is necessary. c. judgment d. e. After considering alternatives to surgery, the client elects to have the procedure. 33. 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? a. Ask the client to explain why he constantly request the nurse b. Encourage the client to verbalize his feelings about the nurse c. Reassure the client that his request will be met whenever possible. d. Advise the client that assignments are not based on client requests 34.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? a. Call the radiology department b. Reinsert the implant into the vagina c. Apply double gloves to retrieve the implant for disposal. d. Place the implant in a lead container using long-handled forceps 35. The client with which type of wound is most likely to need immediate intervention by the nurse? a- Laceration b- Abrasion c. Contusion d. Ulceration 36. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest pri- ority for inclusion in this client’s plan of care? a. Record urine output every hour b. c. cEvaluate neurological status d- Maintain seizure precautions 37. When caring for a client who has acute respiratory distress syn- drome (ARDS), the nurse elevates the head of the bed 30 de- grees. What is the reason for this intervention? a. To reduce abdominal pressure on the diaphragm b. to promote retraction of the intercostal accessory muscle of respiration c. to promote bronchodilation and effective airway clearance d. to decrease pressure on the medullary center which stimulates breathing 38. 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 mus- cle. What is the most likely explanation for failure to locate the gallbladder by palpation? a. The client is too obese b. Palpating in the wrong abdominal quadrant c. The gallbladder is normal d- Deeper palpation technique is needed Rationale: A normal healthy gallbladder is not palpable. 39.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? a. Describe the transmission of drugs to the infant through breast milk b. Encourage her to use stress relieving alternatives, such as deep breathing exercises c. d. Explain that anxiety is a normal response for the mother of a 3-week- old. 40. 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? a. obtain a serum potassium level b. administer the client's usual dose of insulin c. assess pupillary response to light d. Start an intravenous (IV) infusion of normal saline Rationale: The nurse should first start an intravenous infusion of normal saline to replace fluids and electrolytes because the client has been vom- iting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all sugges- tive of hyperglycemia, which also contributes to diuresis and fluid elec- trolyte imbalance. 41. A client who received multiple antihypertensive medications expe- riences 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? a. Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure b. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness c. d. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension. 42. Which client is at the greatest risk for developing delirium? a- An adult client who cannot sleep due to constant pain. b- an older client who attempted 1 month ago c. a young adult who takes antipsychotic medications twice a day d. a middle-aged woman who uses a tank for supplemental oxygen 43. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? a. Reduce risks factors for infection b. Administer high flow oxygen during sleep c. Limit fluid intake to reduce secretions d. Use diaphragmatic breathing to achieve better exhalation 44. Which location should the nurse choose as the best for be- ginning a screening program for hypothyroidism? a- A business and professional women's group. b- An African-American senior citizens center c. A daycare center in a Hispanic neighborhood d. An after-school center for Native-American teens 45.A female client has been taking a high dose of prednisone, a corti- costeroid, for several months. After stopping the medication abruptly, the client reports feeling “very tired”. Which nursing inter- vention is most important for the nurse to implement? a. Measure vital signs b. Auscultate breath sounds c. Palpate the abdomen d. Observe the skin for bruising 46.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? a. capillary glucose b. urine specific gravity c. Serum calcium d. white blood cell count 47. What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? a. working together can decrease the risk for back injury b. c- Using two or three people increases clientsafety. d- turning instead of pulling reduces the likelihood of skin damage 48.A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client? a. Plain yogurt with sweetened with raw honey b. Peanuts in the shell, roasted or un-roasted. c. Aged farmer’s cheese with celery sticks d. Baked apples topped with dried raisins Rationale: A patient with chemotherapy-induced severe neutropenia is at high risk for infection. A low bacteria diet is required D is a healthy snack for a client receiving chemotherapy. A, B and C have a high bacte- rial count and should be avoided. 49. Which action should the school nurse take first when conducting a screening for scoliosis? a. Compare dorsal measurement of trunk b. Extend arms over head for visualization c. Inspect for symmetrical shoulder height. d. Observe weight-bearing on each leg. 50. 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? a. Instruct the UAP to count the client apical pulse rate for sixty seconds b. Determine if the UAP also measured the client’s capillary refill time. c. Assign a practical nurse (LPN) to determine if an apical radial deficit is present. d. Notify the health care provider of the abnormal pulse rate and pulse volume. 51. 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 treat- ed at an outpatient clinic. Which intervention is more important to include in this client’s discharge plan? a. Describe the signs and symptoms of hypoglycemia. b. c- Reinforce the need to continue outpatient treatment d- Suggest wearing a medical alert bracelet at all time. Hypo- glycemic episodes, which can become life-threating. 53-A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform? a- Observe the antecubital fossa for inflammation. 54. The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication’s effectiveness, which labora- tory values should the nurse monitor? Select all that apply a. b. 55.A client is admitted to isolation with the diagnosis of active tuber- culosis. Which infection control measures should the nurse imple- ment? a. Negative pressure environment b. contact precautions c. droplet precautions d. protective environment 56.A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child? a- Sitting up and leaning forward 57.A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is trans- ferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? a- Altered consciousness within the first 24 hours after injury. 58.A female client with breast cancer who completed her first chemo- therapy treatment today at an out-patient center is preparing for dis- charge. Which behavior indicates that the client understands her care needs a- Rented movies and borrowed books to use while passing time at home 59. Which instruction should the nurse provide a pregnant client who is complaining of heartburn? a. Limit fluids between meals to avoid over distension of the stomach b. Take an antacid at bedtime and whenever symptoms worsen c. Maintain a sitting position for two hours after eating. d. . Rationale: Eating small frequent meals throughout the day decreases stomach fullness and helps decrease heartburn. Fluids should not be consumed with foods because they further distend the stomach, but flu- ids not be limited between meals (A) because this puts the client at risk for dehydration. (B) is not recommended during pregnancy unless pre- scribed by the health provider because they place the client at risk for electrolyte imbalance (sodium), constipation (aluminum, or diarrhea (magnesium) (C) is less effective than (D) preventing heartburn. 60.A client is admitted to the intensive care unit with diabetes in- sipidus due to a pituitary gland tumor. Which potential complica- tion should the nurse monitor closely? b- Ketonuria. c. Peripheral edema d. Elevated blood pressure 61.A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement? a- Digitally check the client for a fecal impaction 62. After changing to a new brand of laundry detergent, an adult male report that he has a fine itchy rash. Which assessment finding war- rants immediate intervention by the nurse? a- Bilateral Wheezing. 63. The nurse should teach the parents of a 6 year-old recently diag- nosed with asthma that the symptom of acute episode of asthma are due to which physiological response? a- Inflammation of the mucous membrane & bronchospasm 64.A 10-year-old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond? a- "The heart will stop beating & you will stop breathing." 65. The nurse is assessing a 3-month-old infant who had a pyloroto- my yesterday. This child should be medicated for pain based on which findings? Select all that apply: a. Restlessness b. c- Increased pulserate d- Increased respiratory rate. e- Increased temperature f- Peripheral pallor of the skin 66. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication? a. Ask the client about soft foods preferences b. Auscultate the client’s breath sounds c. Obtain and record the client’s vital signs d. Determine which side of the body is weak. 67. The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse? a. Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing. b. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-pratt drain. c. Collapsed lung after a fall 8h ago with 100 ml blood in the chest tube collection container d. 68. The nurse is caring for a client who had gastric bypass surgery yes- terday. Which intervention is most important for the nurse to imple- ment during the first 24 postoperative hours? a. Insert an indwelling urinary catheter b. Monitor for the appearance of an incisional hernia c. Instruct the client to eat small frequent meals d. Measure hourly urinary output. 69. When preparing to discharge a male client who has been hospital- ized for an adrenal crisis, the client expresses concern about hav- ing another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement? a. Administer anti=anxiety medication prior to providing discharge instructions b. c. Obtain a blood cortisol level after last dose of synthetic ACTH d. Encourage the healthcare provider to delay the client’s discharge. 70. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one-day kill her, she keeps hoping that he will change. What action should the nurse take first? a. Report the finding to the police department b. Discuss treatment options for abusive partners c. Determine the frequency and type of client’s abuse d. Explore client’s readiness to discuss the situation. 71. In caring for a client with Cushing syndrome, which serum labo- ratory value is most important for the nurse to monitor? a. Lactate b. Glucose c. Hemoglobin d. Creatinine 72. Azithromycin is prescribed for an adolescent female who has low- er lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client? a. Have partner screened for human immunodeficiency virus b. Report a sudden onset arthralgia to the healthcare provider c. Decrease intake of high-fat-foods, caffeine, and alcohol d. Use two forms of contraception while taking this drug. 73.A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication? a. Olanzapine b. Divalproex. c. Lorazepam d. Fluoxetine 74.A male client who is admitted to the mental health unit for treat- ment 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? a. Blood alcohol level of 0.09% b. c- Six hours of sleep in the past threedays. d- Weight loss of 10 pounds (4.5 kg) in past month. 75.A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client’s EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, “I feel like an elephant just stepped on my chest” The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform? a. Increase the peripheral IV flow rate to 175 ml/hr to prevent hypotension and shock b. c. Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac enzymes levels. d. Notify the healthcare provider of the client’s increase chest pain a call for the defibrillator crash cart. 76.The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan? a- Literacy level b. Prevalent learning style c. Median age d. Percent with internet access. 77.A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet? a. Eat approximated the same amount of leafy green vegeta- bles daily so the amount of vitamin K consumed is consis- tent. b. Avoid eating all foods that contain any vitamin K because it is an antagonist of Coumadin. c. Increase the intake of dark green leafy vegetables while taking Coumadin d. Eat two servings of raw dark green leafy vegetables daily and continue for 30 days after Coumadin therapy is completed. 78.A client who had a small bowel resection acquired methicillin resis- tant staphylococcus aureus (MRSA) while hospitalized. He treated and released but is readmitted today because of diarrhea and dehy- dration. It is most important for the nurse to implement which inter- vention. a- Maintain contact transmission precaution b- Review white blood cell (WBC) count daily c. Instruct visitors to gown and wash hands d. Collect serial stool specimens for culture 79.A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/minute. What action should the nurse take? a. Provide oxygen 100% via facemask b. Check peripheral tendon reflexes c. Give another IV dose of morphine d. Administer Naloxone IV Rationale: naloxone, the antidote for morphine, is indicated for respira- tory depression below 10 breath/minute A is indicative for oxygen satu- ration is low. B is not indicated at this time. Another dose of morphine within the prescribed time interval © can cause a further decline in the respiratory rate, which could be life-threatening. 80. Which intervention is most important for the nurse to include in the plan of care for an older woman with osteoporosis? a. Evaluate the client’s orientation to time and place b. Place the client on fall precautions c. Encourage the client to drink milk with meals d. Assess the client’s breath sounds daily. Rationale: Osteoporosis causes bone to become brittle, fragile and less dense with age, which increases an older client’s risk for falls and frac- tures which increases their risk for another pathology. 81. Based on the information provided in this client’s medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record) a. Apply oxygen 10 l/mask b. Stop the oxytocin infusion c. Turn the client to the right lateral position. d. Continue to monitor the progress of labor. 82. An unlicensed assistive personnel UAP leaves the unit without noti- fying 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.) 1. Note date and time of the behavior. 2. 3. Plan for scheduled break times. 4. Evaluate the UAP for signs of improvement. t 83.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? a. Gastric output of 900 mL in the last 24 hours b. c- Increased blood urea nitrogen (BUN) d- 24-hour intake at the current infusion rate. 84. Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms? a. Neutrophils b. Lymphocytes c- Eosinophils d- Monocytes 85. 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? a. Explain the healing from injury can take many months b. . c. Encourage the client to verbalize her fears about the pain d. Complete an assessment of the client’s functional ability. 86. One day following an open reduction and internal fixation of a com- pound fracture of the leg, a male client complains of “a tingly sensa- tion” 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? a. Reduce pulmonary ventilation and oxygenation related to fat embolism. b. c. Wound infection and delayed healing to fractured bone protrusion. d. Venous stasis and thrombophlebitis related to postoperative immobility. 87. 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? a- Sluggish pupillary response to light b- Clear fluid leaking from the nose. c- Complaint of severeheadache d- Periorbital ecchymosis of right eye. 88.A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff’s sign). Which patho- physiological mechanism supports this response? a. Arterial Constriction b. c- Poor temperature control d- Severe dehydration. Rationale: Uhthoff’s sign results from temporary vasodilation 89. While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement? a. Determine of aspirin was given prior to radial artery catheter insertion. b. c. Irrigate the arterial line using a syringe with sterile saline d. Administer a PRN analgesic and assess numbness in 30 mints 90.A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor? a. Slow increasing intracranial pressure (ICP) b. Decerebrate posturing c. d- Coup contrecoup signs Rationale: Epidural hematomas results from arterial bleeds that cause a rapid increase in ICP, which initially manifested by an early and rapid onset of decreased consciousness. Slowly increasing ICP is more likely to occur with a venous subdural hematoma. 91. The nurse finds a client at 33 weeks’ gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement? a. Apply oxygen by mask after opening the airway b. c. Give continuous compression with a ventilation ratio at 20:3 d. Apply less compression force to reduce aspiration t 92. When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client’s discharge teaching plan? b- Seek counseling for body image concerns c. Follow instruction for self-care toileting d. Frequently empty bladder to avoid distension. 93. For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gas- troenteritis. Which finding requires the nurse to take further action? a. Loss of appetite b. Serum K 4.0 mEq/or mmol/dl (SI) c. Loose, runny stool d. Tented skin turgor. 94. After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take? a. Note the skin color around the area b. Measure the degree of… c. d- Palpate the temperature of the area. 95. The nurse enters a client’s room and observes the client’s wrist re- straint secured as seen in the picture. What action should the nurse take? a. Use a full knot to secure the restrain tie. b. c- Raise the button side rail of the client’sbed d- Document that the restrain is secured. Rationale: Restraints should be secured to the bedframe, which is more 96.A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-con- trol ventilator using 50% FIO2. Which assessment finding war- rants immediate intervention by the nurse? a. Premature atrial contractions (PAC) b. Hemoccult-positive nasogastric fluid c- Diminished left lower lobe sounds. d- Increasing endotracheal secretions. Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required immediate chest tube insertion to re- in- flate the lung. A and B are common complications that result from in- creased stress in all body systems but are not immediately life threaten- ing. 97. The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occur- rence. (Place the first event on top and the last on the bottom) 1. 2. 3. plaques 5. Vessel narrowing results in ischemia. 98. Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenecto- my. 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? a. This output is not sufficient to cleat nitrogenous waste b. Oliguria signals tubular necrosis related to hypoperfusion c. Low urine output puts the client at risk for fluid overload d. An increased urine output is expected after splenectomy 99.A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective? a. Client geographic location and age b. Number of staff and number of clients c. Weekend and weekday staff availability d. Skills of staff and client acuity Rationale: D considers both client need and staff competence. 100.When performing postural drainage on a client with Chronic Ob- structive Pulmonary Disease (COPD), which approach should the nurse use? a. Perform the drainage immediately after meals b. Instruct the client to breath shallow and fast c. Obtain arterial blood gases (ABG’s) prior to procedure d. Explain that the client may be placed in five positions 101.A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of move- ments that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell’s palsy rather than a stroke? a- Slow onset of facial drooping associated with headache b- Inability to close the affected eye, raise brow, or smile c- A flat nasolabial fold on the right resulting in facial asymmetry. d- Drooling is present on right side of the mouth, but not on the left. 102. The nurse is teaching a client how to perform colostomy irriga- tions. When observing the client’s return demonstration, which ac- tion indicated that the client understood the teaching? a. Turns to left the side to instill the irrigating solution into the stoma b. c. Instills 1,200 ml of irrigating solution to stimulate bowel evacuation d. Inserts irrigating catheter deeper into stoma when cramping occurs 103. The nurse should teach the client to observe which precaution while taking dronedarone? a. Stay out of direct sunlight b. Avoid grapefruits and its juice c. Reduce the use of herbal supplements d. Minimize sodium intake. 104.A client who sustained a head injury following an automobile colli- sion is admitted to the hospital. The nurse includes the client’s risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased? a. Increased Glasgow coma scale score. b. Nuchal rigidity and papilledema. c. Confusion and papilledema d. Periorbital ecchymosis. 105. The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection? a. Remind staff to follow protective environment precautions b. Gently flush the catheter lumen with sterile saline solution c. Cleanse the site and change the transparent dressing. d. Confirm the necessity for continued use of the CVC. increases the risk for infection © 106. During an annual physical examination, an older woman’s fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow- up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)? a. An increased thirst with frequent urination b. Blood glucose range during past two weeks was 110 to 125 mg/dl or 6.1 to 7.0 mmol/L(SI) c. Two-hour postprandial glucose tolerance test (GTT) is 160 mg/dL or 8.9 mmol/L (SI) d. Rationale: FBS grater that 126 mg/dL or 7.0 mmol/L (SI) glucose (normal FBS range 70-110 mg/dL or 3.9 to 6.1 mmol/L (SI)) on at least two occasions is most diagnostic for DM. Classic symptoms of polyphagia, polydipsia, and polyuria may not be present in type…. 107.A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take? a. Provide reassurance to the client that these feeling are normal after delivery b. Discuss delaying the client’s discharge from the hospital for another 24 hrs. c. d. Explain the differences between postpartum blues and postpartum depression. 108.A client who was admitted yesterday with severe dehydration is complaining of pain a 24-gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse imple- ment first? a. Establish the second IV site b. Asses the IV for blood return c. Stop the normal saline infusion. d. Discontinue the 24-gauge IV 109. An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck’s skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client’s plan care? a. Evaluate her response to narcotic analgesia b. Asses the skin under the traction moleskin c. Place a pillow under the involved lower left leg d. Ensure proper alignment of the leg in traction. proper alignment ensures the transaction the fractured bone, and minimize muscle spasms and surrounding tissue injury related to the fracture. A should be implement but improper pull 110. 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 ap- pointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding? a. Immediately apply a pressure dressing b. c- Irrigate the wound with sterilesaline d- Obtain a capillary INR, measurement Rationale: Appearance of granulation tissue is the best indicator of increased venous retuns and ongoing wound healing 111. At the end of a preoperative teaching session on pain manage- ment techniques, a client starts to cry and states, “I just know I can’t handle all the pain.” What is the priority nursing di- agnosis for this client? a. Knowledge deficit b. Anxiety c. Anticipatory grieving d. Pain (acute) 112. The nurse notes a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during la- bor. What intervention should the nurse implement immediately? a. Administer oxygen by face mask at 6L/mint b. Transport the client for a cesarean delivery c- Elevate the presenting part off the cord. d- Place the client to a knee-chest position. 113.A client who had a right hip replacement 3 day ago is pale has di- minished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client’s symptoms, what recommendation should the nurse give the healthcare provider? a- Reassess readiness for SNF transfer. b- Obtain specimens for culture analysis c. Confer with family about home care plans d. Arrange physical therapy for strengthening. 114.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.) a. Take an additional dose for signs of hyperglycemia b. c. d. Use sliding scale insulin for finger stick glucose elevation. e. Take Glucophage with the morning and evening meal. 115. The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational mate- rials include which characteristics? Select all that apply a. Written at a twelfth-grade reading level b. Uses common words with fewSyllables d. Printed using a 12-point type font e. Uses pictures to help illustrate complex ideas 116. During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client’s point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location) a- 117. An older male adult resident of long-term care facility is hospital- ized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disori- ented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.) a. Recommend a 24-hour caregiver on discharge to the long- term facility. b. c. d. Request immediate evaluation by Rapid Response Team e. Apply soft wrist restraints so that the operative site is protected. 118. An older male comes to the clinic with a family member. When the nurse attempts to take the client’s health history, he does not respond to questions in a clear manner. What action should the nurse imple- ment first? a. Ask the family member to answer the questions. b. Provide a printed health care assessment form c. d- Defer the health history until the client is less anxious. that noise and distraction have been minimized…. 119. The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need? a. Treatment for acute uremic symptoms within 24 hours b. Change to a regular diet c. d- Unrestricted sodium intake Rationale: This client, whose output is significantly high will need fluids and electrolyte replacement.The diuretic stage of ARF begins when the client has greater than 500 ml of urine in 24 hrs. A is associated with the oliguric and anuric stage of ARF. B and D should not occur until the client’s BUN and electrolytes indicate a significant improvement that will allow for such changes. 120. Which intervention should the nurse include in the plan of care for a child with tetanus? a. Open window shades to provide natural light b. Reposition side to side every hour. c. d- Encourage coughing and deep breathing 121. Suicide precautions are initiated for a child admitted to the men- tal health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client’s room. Which intervention is most important for the nurse to im- plement? a. Assign a sitter for constant observation b. Screen future visitors for contraband c. Document suicide monitoring frequently d. Remove cigarettes for the client’s room. Rationale: Safety is the priority, and any items that might cause self- 122.A family member of a frail elderly adult asks the nurse about eli- gibility requirements for hospice care. What information should the nurse provide? (Select all that apply.) a. All family must agree about the need for hospice care. b. Hospice services are covered under Medicare Part B. c. d. e. All medications except pain treatment will be stopped during hospice care. 123. A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client’s teaching plan? a. Keep an antidote available in the event of hemorrhage b. Continue obtaining scheduled laboratory bleeding test c. Eliminate spinach and other green vegetable in the diet. d. 124.A nurse with 10 years’ experience working in the emergency room is reassigned to the perinatal unit to work an 8-hour shift. Which client is best to assign to this nurse? a. A client who is leaking clear fluid b. A mother who just delivered a 9 pounds boy c. A mother with an infected episiotomy. d. A client at 28- weeks’ gestation in pre-term labor. Rationale: An infected episiotomy is essentially an infected surgical 125. An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first? a. Spironolactone b. Potassium c. Ampicillin sodium parental d. Digoxin. 126. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN? a. . b. Transport a client who is receiving IV fluids to the radiology department. c. Administer PRN oral analgesics to a client with a history of chronic pain d. Complete ongoing focused assessments of a client with wrist restrain. 127. While teaching a young male adult to use an inhaler for his new- ly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take? a. Remind the client that a rescue inhaler might save his life b. Leave the client alone so that he can grieve his illness c. Ask the client what he is thinking about at his time. d- Gently touch the client then continue with teaching. 128. After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and short- ness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While complet- ing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse imple- ment? (Select all that apply.) a. Apply oxygen via nasal cannula b. Obtain 12 leadelectrocardiogram. d- Monitor continuous oxygen saturation. e- Give PRN dose of regularinsulin 129. The nurse caring for a 3-month-old boy one day after a pyloroto- my notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take? a- Administer a prescribed analgesia for pain. b- Increase IV infusion rate for rehydration c. Provide additional blankets to increase body temperature d. Feed one ounce of formula to correct hypoglycemia. 130. Two days after admission a male client remembers that he is al- lergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? (Select all that apply) a. Notify the food services department of the allergy. b. Enter the allergy information in the client’s record. c- Document the statement in the nurse’snotes d. Note the allergy on the diet intake flow sheet e. Add egg allergy to the client’s allergy arm band. . 131. The rapid response teams detect return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement? a- Perform bilateral chest auscultation. b- Resume compression for 2 minutes c. Administer a dose of epinephrine d. Program the monitor for cardioversion. 132. After administering an antipyretic medication. Which in- tervention should the nurse implement? a- Encouraging liberal fluid intake 133.A client with hyperthyroidism is being treated with radioactive io- dine (I-131). Which explanation should be included in preparing this client for this treatment? a. Explain the need for using lead shields for 2 to 3 weeks after the treatment b. Describe the signs of goiter because this is a common side effect of radioactive iodine c. Explain that relief of the signs/symptoms of hyperthyroidism will occur immediately d. Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider ad- ministered by mouth and the client is observed for signs of thyroid storm. 85% of clients are cure by one dose. The dose of radioactivity is not enough to warrant (A). B is indicated for a client receiving iodine or iodine compound medications in the treatment of hyperthyroidism. It takes 3 to 4 weeks for sings of hyperthyroidism to subside. 134. After a colon resection for colon cancer, a male client is moaning while being transferred to the Post anesthesia Care Unit (PACU). Which intervention should the nurse implement first? a. Assess the client’s dressing for bleeding b. respirations c. Administer a PRN dose of IV Morphine d. Check the client’s orientation to time and place. Rationale: Colon resection, a major abdominal surgical procedure, causes severe pain in the immediate postoperative period and requires administration of IV morphine regularly to maintain analgesic serum level.Before administering a central nervous system depressing anal- gesia, the client’s vital signs should be assessed to determine the client’s current level of CNS depression 135. The nurse is caring for a group of clients with the help of a li- censed practical nurse (LPN) and an experienced unlicensed as- sistive personnel (UAP). Which procedures can the nurse dele- gate to the UAP? (Select all that apply) a. Change a saturated surgical dressing for a client who had an abdominal hysterectomy. b. c. Start a blood transfusion for client who had a below-the knee amputation. d. e. 136.A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement? a. Reposition the client in a side-lying position and support his abdomen with pillows. b. Elevate the client’s feet on a pillow while keeping the head of the bed elevated. c. d. Place the client in a shock position and monitor his vital signs at frequent intervals. 137.A client with a chronic health problem has difficulty ambulating short distance due to generalized weakness butcan bear weight on both legs. To assist with ambulation and provide the greatest stabili- ty, what assistive device is best for this client? a. A quad cane b. Crutches with 2-point gait. c. Crutches with 3-point gait. d. Crutches with 4-point gait. 138.The nurse uses the parkland formula (4ml x kg x total body sur- face area = 24 hours’ fluid replacement) to calculate the 24- hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.) a- Answer: 12160 Rationale: 4ml x 76kg x 40 (bsa) =12,160 ml 139.A client with leukemia undergoes a bone marrow biopsy. The client’s laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? a. Assess body temperature b. Monitor skin elasticity c. d- Measure urinary output 140.An 18-year-old female client is seen at the health department for treatment of condyloma acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement? a. Tell the client that the vaccine for HPV is not indicated b. Inform the client that warts do not return following cryotherapy c. Recommended the use of latex condoms to prevent HPV transmission. d. 141.A client admitted to the psychiatric unit diagnosed with major de- pression wants to sleep during the day, refuses to take a bath, and re- fuses to eat. Which nursing intervention should the nurse implement first? a. Assess the client’s ability to communicate with the other staff members b. Arrange a meeting with the family to discuss the client’s situation c. Administer the client’s antidepressant medication as prescribed. d. Establish a structured routine for the client to follow. 142.A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? a. Decrease urinary output b. Low blood glucose level c. Profound weight gain d. Ventricular arrhythmias. 143.The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blis- ters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? a. b. Encourage the mother to apply lotion with each diaper charge c. Tell the mother to cleanse with soap and water at each diaper change d. Ask the mother to decrease the infant’s intake of fruits for 24 hours. 144.A resident of a long-term care facility, who has moderate de- mentia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement? a. Allow client to choose foods from a menu b. Assign a staff member to feed the client c. Have meals brought to the client’s room d. Encourage the client to eat finger foods. 145.A client is receiving mesalamine 800 mg PO TID. Which as- sessment is most important for the nurse to perform to assess the effectiveness of the medication? a. Pupillary response b. Oxygen saturation c. Peripheral pulses d. Bowel patterns 146.While in the medical records department, the nurse observes several old medical records with names visible in waste container. What ac- tion should the nurse implement? a. Place the records in a separate trash bag and tie the bag securely closed b. Point out the record to a worker in the medical records department c. Contact the medical records department supervisor. d- Immediately remove and shred the records. 147.A 16-year-old adolescent with meningococcal meningitis is re- ceiving a continuous IV infusion of penicillin G, which is pre- scribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.) a- Answer 83 Rationale: 1000 ml-----12hr. Xml ---------1hr. 1000/12 = 83.33 = 83. 148.While visiting a female client who has heart failure (HF) and os- teoarthritis, the home health nurse determines that the client is hav- ing more difficulty getting in and out of the bed than she did previ- ously. Which action should the nurse implement first? a. Inquire about an electric bed for the client’s home use b. therapist. c. Explain the usual progression of osteoarthritis and HF d. Request social services to review the client’s resources. 149.A client has an intravenous fluid infusing in the right forearm. To determine the client’s distal pulse rate most accurately, which action should the nurse implement? a. Elevate the client’s upper extremity before counting the pulse rate b. Auscultate directly below the IV site with a Doppler stethoscope c. Turn off the intravenous fluids that are infusing while counting the pulse. d. 150.A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement? b- Commend the UAP for implementing the proper position c. Tell