RN EXIT EXAM NEW 2023

RN EXIT EXAM NEW 2023 1. A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the following is an appropriate documentation of the findings? b. Murmur at the mitral area 2. A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the clients indicates an understanding of the teaching? c. I will remove bananas from my diet 3. A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin? c. Renal insufficiency 4. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? a. Contractions - 5. A nurse on a surgical pediatric care unit receives report prior to providing care for a group of clients. Which of the following clients should the nurse assess first? d. I will determine which muscles to contract by stopping and starting my stream of urine 6. A nurse is teaching a client how to perform kegel exercises. Which of the following client statements indicates understanding of the teaching? I will determine which muscles to contract by stopping and starting my stream of urine 7. A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which of the following statements indicates that the client understands the teaching? b. I should urinate before the test8. A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago. Which of the following findings should the nurse expect? c. Elevated temperature 9. A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following clinical manifestations is an expected finding for this client? b. Scratchy, high pitched sound upon chest auscultation 10. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? b. Consume food high in bran fiber 11. A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse? b. Privately interview the client about her condition. 12. A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority? a. Maintain NPO status for client(ABC) 13. A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? b. “I will need to increase my insulin doses later in my pregnancy” 14. A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first? a. Test the client for Trousseau’s sign15. A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching? c. “I should change the stoma pouch every day” 16. A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity? a. Hyporeflexia 17.A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg(9.5 lbs). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero) Answer is 1.7 mL per dose Rationale: 100mg X 4.34 kg= 434 mg/day 434mg/125mgX1=3.472/day 3.472/2= 1.736 18.A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make? a. “Your desire to be an organ donor must be documented in writing” 19.A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate? a. Administer enalapril 2.5 mg PO twice daily 20.A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? b. Clamp the catheter distal to the injection port21. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations? A. Orthostatic Hypertension 22. A nurse is devdeloping an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? B. The client exhibits impulsive behavior. 23. A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider? B. Protruding Hemorrhoids 24. A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to take first? A. Inform the provider of the time of the last dose of pain medication. 25. A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report? B. The estimated blood loss was 250 milliliters. 26. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? D. “Have your child drink a small glass of water after swallowing the medication.” 27. A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications? A. Left ventricular failure 28. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?D. A client who is receiving heparin for deep vein thrombosis. 29. A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? A. Fasting blood glucose 108 mg/dl (WNL) 30. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? Paul for 158 would u pick D? D. Use clothing with buttons and zippers. 31. The clinic nurse is obtaining cardiovascular data on a client. The LPN/LVN prepares to check the client's apical pulse and places the stethoscope in which position? 4. At the midclavicular line at the fifth left intercostal space 32) The LPN/LVN is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L. The client asks the nurse why the oxygen 3. Deficient oxygenation to heart cells results in angina pectoris pain. 33) The licensed practical nurse (LPN) is assisting in caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The registered nurse administers morphine sulfate to the client as prescribed by the health care provider. Following administration of the morphine sulfate, the LPN plans to monitor which indicator(s)? 3. Respirations and blood pressure 34) A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions? 4. "I need to adhere to my dietary restrictions." 35) The LPN/LVN is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage does the nurse instruct the client to select from the menu?4. Lemonade 36) The LPN/LVN is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which question? 2. "Where is the pain located?" 37) The LPN/LVN has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 3. "I should routinely use polyunsaturated oils in my diet." 38) The LPN/LVN is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia? 1. Tall, peaked T waves 39) The LPN/LVN is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia? 2. ST-segment depression 40) While the nurse is involved in preparing a client for a cardiac catheterization, the client says, "I don't want to talk with you. You're only the nurse. I want my doctor." Which response by the nurse should be therapeutic? 3. "So you're saying that you want to talk to your health care provider?" 41) The LPN/LVN reinforces instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information? 2. "I should avoid sitting in one position for long periods of time." 42) A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. The LPN/LVN interprets that the client is experiencing which type of angina? 1. Stable43) The LPN/LVN is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. Which statement by the client indicates a need for further teaching? 2. "It is best to exercise once a week for an hour." 44) The LPN/LVN is working with a client who has been diagnosed with Prinzmetal's (variant) angina. The nurse plans to reinforce which information about this type of angina when teaching the client? 4. Prinzmetal's angina is generally treated with calcium channel blocking agents. 45) The LPN/LVN working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse should interpret that the pain is likely a result of myocardial infarction (MI) if which observation is made by the nurse? 3. The pain has not been unrelieved by rest and nitroglycerin tablets. 46) The LPN/LVN is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to the client to try to motivate the client to quit smoking? 4. "If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years." 47) A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and furosemide (Lasix) as ongoing prescribed medications. The nurse teaches the client to report which sign/symptom that indicates the medications are not producing the intended effect? 3. Weight gain of 2 to 3 pounds in a few days 48) A client has experienced an episode of pulmonary edema. The LPN/ LVN determines that the client's respiratory status is improving if which breath sounds are noted? 3. Crackles in the lung bases 49) A client in pulmonary edema has a prescription to receive morphine sulfate intravenously. The licensed practical nurse assisting in caring for the client determines that the client experienced an intended effect of the medication if which is noted? 2. Relief of apprehension50) The LPN/LVN is providing discharge teaching for a post-myocardial infarction (MI) client who will be taking 1 baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement? 1. "I will take this medication every day." 51) The LPN/LVN determines that a client with coronary artery disease (CAD) needs further teaching about disease management if the client makes which statement? 2. "I will avoid walking for exercise. 52) The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder? 3. The client complains of leg edema, and skin breakdown has started. 53) A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which statement by the client indicates understanding of this stress reduction measure? 4. "The best thing about this is that I can use it anywhere, anytime." 54) A client, who is 36 hours post-myocardial infarction, has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation is made? 3. The pre activity pulse rate is 86 beats per minute; the post activity pulse rate is 94 beats per minute. 55) The nurse is planning a dietary menu for a client with heart failure being treated with digoxin (Lanoxin) and furosemide (Lasix). Which would be the best dinner choice from the daily menu? 2. Baked pollock, mashed potatoes, and carrot-raisin salad 56) A client has received instructions about an upcoming cardiac catheterization. The nurse determines that the client has the best understanding of the procedure if the client knows to report which symptoms? 1. Chest pain 57) The nurse is caring for a client diagnosed with Buerger's disease. Which finding should the nurse determine is a potential complication associated with this disease?3. Numbness and tingling in the legs 58) The nurse has completed nutritional counseling with an overweight client about weight reduction to modify the risk for coronary artery disease (CAD). The nurse should determine the teaching is successful if the client states that which weight loss goal is safe? 2. Two pounds per week 59) The nurse has reinforced instructions to the family of an older client who seems anxious about being discharged after cardiac surgery. The nurse understands further teaching is needed if a family member makes which statement? 4. "A daily half-mile-long brisk walk generally helps people bounce back more quickly and provides more of a sense of control." 60) The nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as indicative of which finding? 3. Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease 61) The nurse has completed counseling about smoking cessation with a client with coronary artery disease (CAD). The nurse determines that the client has understood the material best if the client makes which statement? 1. "A smoker has twice the risk of having a heart attack as a nonsmoker." 62) The nurse has given simple instructions on preventing some of the complications of bed rest to a client who experienced a myocardial infarction. The nurse should intervene if the client was performing which of these contraindicated activities? 3. Isometric exercises of the arms and legs 63) A client with a diagnosis of heart failure (HF) is preparing for discharge to home from the hospital. Which condition indicates the client is ready for discharge to home? 4. The client can verbally describe the daily medications, doses, and times to be administered.64) A client admitted to the hospital with coronary artery (CAD) disease complains of dyspnea at rest. The nurse determines that which would be of most help to the client? 2. Elevating the head of the bed to at least 45 degrees 65) The nurse is evaluating the effects of care for the client with deep vein thrombosis. Which limb observations should the nurse note as indicating the least success in meeting the outcome criteria for this problem? 1. Pedal edema that is 3+ 66) A client is at risk for complications of heart failure. Which is the nurse's priority for early detection of the most likely cause of complications with this client? 3. Evaluating total body fluid 67) A female client complains of an "odd, left-sided, twinge-like pain" along the anterior axillary line and states she has had this feeling for the past 3 days. Which is the initial action? 3. Determine if the pain is cardiac in origin. 68) A client's blood pressure is 100/78 mm Hg; the client has tachycardia and is cool and pale. The nurse assists the client to which position to promote tissue oxygenation and alleviate hypoxia? 3. Semi-Fowler's 69) The nurse notes this rhythm on the client's cardiac monitor. The nurse next reports that the client is experiencing which heart rhythm? 2. Atrial fibrillation 70) The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse institute when providing care for the client? 1. Take daily weights and monitor trends. 71) A hypertensive client who has been taking metoprolol (Lopressor) has been prescribed to decrease the dose of the medication. The client asks the nurse why this must be done over a period of 1 to 2weeks. In formulating a response, the nurse incorporates the understanding that abrupt withdrawal could affect the client in which way? 3. Precipitate rebound hypertension 72) A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation? 4. The ulcer has a brownish or "brawny" appearance. 73) A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed, the nurse places a sign above the bed stating that the client should remain on bed rest and in which position? 3. With the head of the bed elevated no more than 15 degrees 74) A client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned, knowing that this level could lead to which complication? 2. Cardiac arrest 75) A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active? 2. Bilateral lung crackles 76. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor theclient for which of the following manifestations d. Neck vein distention - fluid volume excess 76. A nurse is developing an in service about personality disorders Which of the following information should the nurse include when discussing borderline personality disorder? a. The client is overly concerned about minor details 77. A nurse is assessing a client who is at 36 weeks gestation. Which of the following findings should the nurse report to the provider ? a. 3+ deep tendon reflexes -preeclampsia78. A nurse is administering an analgesic to a client who has a chest tube . The provider is preparing to discontinue the chest tube before the medication has taken effect. Which of the following actions should the nurse take first ? a. Inform the provider of the time of the last does of pain medication 79. A nurse in a PACU is transferring care of a client to a nurse on the medical surgical unit. Which of the following statements should the nurse include in the hand off report ? b. The estimated blood loss was 250 milliliters 80. A nurse is assessing a clients PAWP. The nurse should recognize that an elevated PAWP indicates which of the following complication? a. Left ventricular failure 81. A charge nurse on a medical surgical unit is assisting with the emergency responses plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current client should the nurse recommend for early discharge ? a. A client who has COPD and a respiratory rate of 44/ min - RR is too high out of range 82. A nurse is caring for four client who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery ? b. WBC 9,800 mm3 > 4,800 is normal 83. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching ? c. Establish a toileting schedule for the client 84. A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation? d. Focus on how the conflict occurred85. A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the peripheral IV site. Which of the following actions should the nurse plan to take? c. Please a warm moist compress on the site 86. A nurse is preparing to administer three medications to a client who is receiving continuous enteral tube feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? c. Use a syringe to allow the medications to Flow by gravity 87. The nurse is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect? c. Seductive Behavior 88. A nurse in a prenatal Clinic is teaching a client about non pharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching? c. The nurse will initiate acupuncture when I arrive at the unit - Needles during labor no. 89. A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse report to the provider? c. 2 PVCs per minute 90. A nurse is observing a newly licensed nurse who is administering Total parenteral Nutrition tpn to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene? d. Increases the tpn infusion rate each hour until the prescribed rate is achieved 91. A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. which of the following group facilitation techniques should the nurse include in the teaching? b. Share personal opinions to help influence the group's values -your focus is having group share their personal thoughts and feelings to facilitate discussion 92. A nurse is assessing a client's respirations which of the following actions should the nurse take?d. Count respirations for 1 minute if the rhythm is irregular 93. A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? D) Proceed with the triage process in the same manner as any adult client The correct answer is D: Proceed with the triage process in the same manner as any adult client 94. A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? B) Report hourly outputs of less than 30 ml/hr 95. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? B) Strep throat went through all the children at the day care last month. 96. A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to A) Discuss the feeling of reluctance with an objective peer or supervisor 97. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action A) May result in charges of unlawful seclusion and restraint 98. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? A) Pain related to ischemia 99. The provisions of the law for the Americans with Disabilities Act require nurse managers toB) Provide reasonable accommodations for disabled individuals 100. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance? C) "I have diminished sexual function." 101. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate? D) ”I think I remember that standing cannot be done until after 72 hours." 102. 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? Review with the client the need to avoid foods that are rich in milk and cream 103. 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 103. 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. 104. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate followup? Describes life without purpose105. 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 106. 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 107. 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 108. Rational: reservoir bag should not deflate completely during inspiration and the client’s respiratory rate is within normal limits. 109. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs? Respiratory apnea of 30 seconds 110. 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 111. At 0600 while admitting a woman for a schedule repeat cesarean section (CSection), 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 provider112. 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 113. 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 114. 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 115. 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” 116. 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 117. 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 118. 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 119. Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary management of osteoporosis? Bagel with jelly and skim milk 120. 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 Provide teaching about the need for a tetanus booster within the next 72 hours. have the mother check the child's temperature q4h for the next 24 hours transfer the child to the emergency department to receive a gamma globulin injection 121. 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. 122. 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 123. 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 history124. 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.) 75 125. 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 126. 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 127. 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 rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml 128. 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 Observe for edema around the ankles Measure the client’s capillary glucose level Count the apical and radial pulses simultaneously129. 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 130. 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 131. A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care? C) Contact precautions 132. The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? B) Clean the meatus, begin voiding, then catch urine stream 133. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? B) Watermelon 134. A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? C) Immediately wash the hands with vigor135. As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.” 136. A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? B) Glascow Coma Scale 8, respirations regular 137. A client enters the emergency department unconscious via ambulance from the client’s work place. What document should be given priority to guide the direction of care for this client? C) A notarized original of advance directives brought in by the partner 138. The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistivepersonnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? A) An admission at the change of shifts with atrial fibrillation and heart failure - PN 139. A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? B) Restlessness and increased mucus production 140. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? C) "Clothes are becoming tighter across her abdomen." 141. Which statement best describes time management strategies applied to the role of a nurse manager?C) Set daily goals with a prioritization of the work 142. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this probleminclude which of these? D) Abdominal mass and weakness 143. A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? A) "I will only have to wear this for 6 months." 144. The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will D) Improve team morale 145. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing 146. The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's complaints. The nurse manager's next action should be to D) Request an immediate private meeting with the health care provider and staff nurse 147. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states “I demand to be released now!” The appropriate action is for the nurse toC) Let’s discuss your decision to leave and then we can prepare you for discharge. 148. A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition? B) Heart murmur 149. A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to B) Maintain alveolar surface tension 150. An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority assessment should be C) Respiratory function 151. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care? A) Hourly urine output 152. The charge nurse on the night shift at an urgent care center has to deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style of leadership and decision-making would be best in this circumstance? A) Assume a decision-making role 153. The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance? B) Metabolic alkalosis154. The nurse manager is conducting an in-services education program on the fire evacuation of the newborn recovery. What intervention should the nurse manager disseminate to the staff? Evacuate each infant with mother via wheelchair 155. An adult man reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging in the neighborhood. He expresses concern because both of his deceased parents had heart disease and his father was a diabetic. He lives with his male partner, is a vegetarian, and takes atenolol which maintain his blood pressure at 138/74. Which risk factors should the nurse explore further with the client? Select all that apply History of hypertension. Family heath history. 156.A client with severe full-thickness burns is scheduled for an allografting procedure. Which information should the nurse provide the client? Human source grafts require monitoring for signs of graft rejection 157. The nurse is administering a 750 ml cleansing enema to an adult client. After approximately150 ml of enema has informed, the client states, ‘stop I can’t hold anymore.” What action should the nurse take? Clamp the tubing and instruct the client to breathe deeply before continuing. 158. The nurse requests a meals tray for a client follows Mormon beliefs and who is on clear liquid diet following abdominal surgery. Which meal item should the nurse request for this client? (Select all that apply) Apple juice 159. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (LPN), and unlicensed assistant personnel (UAP). Which task should the charge nurse assign to the RN?Supervised a newly hired graduate nurse during an admission assessment 160. Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medication should be held until a later time? The mucosal barrier, sucralfate (Carafate), for a client diagnosed with peptic ulcer disease.