HESI RN COMPASS EXIT EXAM V1

HESI RN COMPASS EXIT EXAM V1 1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A) Make certain the child is maintained in correct body alignment. 2. The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report immediately to the health care provider? A) Height and weight percentiles vary widely 3. The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse? C) Advise the parents to ignore breath holding because breathing will begin as a reflex 4. The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina? A) "My pain is deep in my chest behind my sternum." 5. Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? A. Checking the client's blood pressure 6. A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." 7. 2-A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should: B. Ask the answering service to contact the on-call physician 8. An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is: B. Asking the ED physician to check the client Correct 9. NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should: A. Administer the antihypertensive with a small sip of water 10. A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? A. "Tell me more about what you’re feeling." 11. A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse’s priority? A. Contacting the physician 12. A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to: A. Call the radiography department to obtain a chest x-ray 13. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis? D) Safety 14. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age? B) They are able to think logically in organizing facts 15. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to B) An occupational therapist from the community center 16. A priority goal of involuntary hospitalization of the severely mentally ill client is C) Protection from harm to self or others 17. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend A) Isometric 18. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report A) Loss of consciousness 19. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would C) Administer a laxative to the client the evening before the examination 20. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? D) Risk for infection 21. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that A) Circumcision is delayed so the foreskin can be used for the surgical repair 22. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect? C) Shallow respirations 23. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings? A) These side effects are common and should subside in a few days 24. A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse? A) Ask the client if he has noticed any bleeding or dark stools . 25. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the C) Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow 26. For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate? A) Institute seizure precautions 27. Following mitral valve replacement surgery a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 micro drops/cc. What rate would deliver 4 mgm of Lidocaine/ minute? A) 60 microdrops/minute 28. The nurse is taking a health history from parents of a child admitted with possible Reye's Syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye's Syndrome? C) Varicella 29. While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of what psychosocialskill? D) Assertion of control 30. A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn assessments suggests to the nurse that the infant has fetal alcohol syndrome? C) Cranial facial abnormalities are noted 31. The nurse is attending a workshop about caring for persons infected with Hepatitis. Which statement is correct when referring to the incidence rate for Hepatitis? A) The number of persons in a population who develop Hepatitis B during a specific period of time 32. A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client? A) Capillary refill less than 3 seconds 33. The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB? The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB? B) Sputum culture 34. The nurse has been teaching an apprehensive primipara who has difficulty in initial nursing of the newborn. What observation at the time of discharge suggests that initial breast feeding is effective? A) The mother feels calmer and talks to the baby while nursing 35. The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The best response by the nurse is C) "All layers of the skin were destroyed in the burn." 36. The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered B) Rude 37. A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child? D) Eating peanuts 38. When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by B) An imbalance between red cell destruction and production 39. The nurse is assessing a newborn delivered at home by an admitted heroin addict. Which of the following would the nurse expect to observe? D) Jitteriness at 24-48 hours 40. The nurse is caring for a client with congestive heart failure. Which finding requires the nurse's immediate attention? A) Pulse oximetry of 85% 41. The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body? A) Inspect the skin 42. Which action is most likely to ensure the safety of the nurse while making a home visit? C) Remain alert at all times and leave if cues suggest the home is not safe 43. An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by A) Tachypnea 44. The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: “We are concerned about the possible occurrence of sudden infant death syndrome (SIDS).” In order to take appropriate action, the nurse must understand that D) 95% of SIDS cases occur before 6 months of age 45. As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid B) Scuba diving 46. The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be C) High protein, high calorie, unrestricted fat 47. A client had arrived in the USA from a developing country 1 week prior. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS with a history of unintended weight loss, drug abuse, night sweats, productive cough and a "feeling of being hot all the time." The nurse should assign the client to share a room with a client with the diagnosis of A) Acute tuberculosis with a productive cough of discolored sputum for over three months 48. A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client? C) Poor skin turgor 49. When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend? B) Deep breathing 50. When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in? D) Playing cooperatively with other preschoolers 51. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding? A) Hold a rattle 52. When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child? D) Explain the surgery using a model of the heart 53. The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments? D) Accept their feelings without judgment 54. When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse? C) Sterile technique for dressing change at IV site 55. When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary artery after a myocardial infarction, which finding would be of greatest concern to the nurse? B) Hematemesis 56. A 52 year-old client is being transfused with one unit of packed cells. A half hour after the transfusion was initiated, the client complains of chills and headache. Which action should the nurse implement first? C) Stop the transfusion 57. An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding episode. Which order should be questioned by the nurse? C) Aspirin for pain management 58. The nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which statement by the mother would indicate the need for further teaching? D) "The therapy can be discontinued when the spots disappear." 59. The nurse is preparing a client for discharge following in-patient treatment for pulmonary tuberculosis. Which of these instructions should be given to the client? B) Continue medication use as prescribed 60. The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse's immediate attention? C) "I am itching all over." 61. A woman diagnosed with bipolar disorder is to take lithium (Lithane) as part of the treatment. What should the nurse discuss with the client as part of the teaching plan?C) Avoidance of alcohol 62. The nurse prepares to administer eye drops to a 6 year-old child. Which of these demonstrates the correct method for instillation of eye drops? D) In the conjunctival sac as the lower lid is pulled down 63. A depressed client is experiencing severe insomnia. The health care provider orders trazadone (Desyrel). The nurse tells the client to expect B) Relief of insomnia 64. A client with diabetes has a blood sugar is 306 this morning. After the nurse reports this lab result and the client's symptoms of excessive hunger and thirst, what would the nurse expect the health care provider to order? B) Regular insulin 65. The nurse is planning to administer otic drops to a 6 year-old child. Which of the following is the correct procedure? A) Hold the pinna up and back to instill the drops 66. A 1 year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time? C) Monitor serum glucose levels 67. Today's prothrombin time for a client receiving Coumadin is 20 (normal range listed by the lab is 10-14). What is the appropriate nursing action? B) Recognize that this is a therapeutic level 68. The nurse administered intravenous gamma globulin to an 18 month-old child with AIDS. The parent asks why this medication is being given. What is the nurse’s best response? C) "This medication is used to prevent bacterial infections." 69. The nurse is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse's immediate attention? D) Blood glucose of 350 mg/dl 70. The nurse is teaching a client with asthma about the correct use of the Azmacort (triamcinolone) inhaler. Which of the following statements, if made by the client, would indicate that the teaching was effective? B) "I should rinse my mouth after using the inhaler." 71. A client is admitted to the hospital because of heart failure and digoxin toxicity. At home, the client was taking digoxin (Lanoxin) and furosemide (Lasix). Which symptom would the nurse anticipate finding on the initial assessment? A) Muscle weakness and cramping 72. The nurse admits a client with hypertension who complains of dizziness after taking diltiazem (Cardizem). Which of the following is the most important information for the nurse to assess? A) Schedule for taking medicine 73. Which of the following classifications of medications would be most often used for clients with schizophrenia? D) Neuroleptics 74. Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt? B) "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?" 75. A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client’s family is alarmed and calls the clinic when "his eyes rolled upward." The nurse recognizes this as what type of side effect? A) Oculogyric crisis 76. Which of the following measures would be appropriate for the nurse to teach the parent of a nine month-old infant about diaper dermatitis? D) Discontinue a new food that was added to the infant's diet just prior to the rash 77. A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying "no" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need? C) Independence 78. Which behavioral characteristic describes the domestic abuser? D) Low self-esteem 79. Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing D) "By prolonging breathing out with pursed lips the little areas in my lungs don't collapse." 80. During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem? C) "I have to turn my head to see my room." 81. A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"? A) "I don't remember anything about what happened to me." 82. While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action? B) Massage the fundus 83. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age? A) Double the birth weight 84. On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to B) Introduce him/herself and accompany the client to the client’s room 85. A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client A) Has increased airway obstruction 86. A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse? A) "Focus on your sons' needs during the first days at home." 87. A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is D) Feelings of alienation or isolation 88. A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize B) Administration of thyroid hormone will prevent problems 89. A Hispanic client refuses emergency room treatment until a curandero is called. Thenurse understands that this person brings what to situations of illness? A) Holistic healing 90. In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in C) Learning, creativity, and judgment 91. In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy doesn't contain sperm, continue to use another form of contraception. rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next? C) Check the client for bladder distention and the client's urinary catheter for kinks 92. The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client complaint calls for immediate nursing action? A) Diaphoresis and shakiness 93. The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be A) Reduce fear and protect self-esteem 94 In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test? B) Unchanged urine specific gravity 95. The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child has D) Delay in achievement of most developmental milestones 96. A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What finding would the nurse expect? D) Hypotension 97. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? A) Until the health care provider has determined that your ejaculate 98. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? C) The flow of life is believed to flow through major pathways or nerve clusters in your body. 99. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? C) Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent 100. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A) Side-lying on the left with the head elevated 10 degrees 101. A client has an indwelling catheter with continuous bladder irrigation After undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? C) minimal drainage into the urinary collection bag 102. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse? C) Participate with the compressions or breathing 103. The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? B) Jugular vein distention 104. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) Can predispose to dysrhythmias 105. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? B) Pupils fixed and dilated 106. A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? D) ”I went to the health care provider last week for a cold and I have gotten worse." 107. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? B) Pale mucosa of the eyelids and lips 108. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is D) Pupil responses 109. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? D) A preschooler with intermittent episodes of alertness 110. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be D) Pale, thin arms and legs, uninterested in surroundings 111. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? D) Hair loss 112. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriatenursing intervention is to B) Administer acetaminophen as ordered as this is normal at this time 113. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be B) Assess for dyspnea or stridor 114. Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? D) I went to the bathroom and my urine looked very red and it didn’t hurt when I went. 115. A middle aged woman talks to the nurse in the health care provider’s office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? D) Fibroids that cause no problems still need to be taken out. 116. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? A) Stay with client and observe for airway obstruction 117. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor? A) FHT 168 beats/min 118. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse’s initial evening rounds the nurse notices a foulsmell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? B) "I have been coughing up foul-tasting, brown, thick sputum." 119. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop 120. Which of these observations made by the nurse during an excretory urogram indicate a complicaton? B) The client’s entire body turns a bright red color 121. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? B) "The tube will remove excess air from your chest." 122. A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet?Select all that apply. A. Smoking C. High alcohol intake D. White or Asian ethnicity 123 A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is: D. Sardines 124 A nurse is providing information to a client with acute gout about home care. Which of the following measures does the nurse tell the client to take? Select all that apply. A. Drinking 2 to 3 L of fluid each day C. Resting and immobilizing the affected area 125 A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. A. Fatigue D. Low-grade fever 126 A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client’s medical record? Select all that apply. A. Fever B. Vasculitis E. Abdominal pain 127 A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply. A. Beer C. Yogurt E. Pickled herring 128 The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should: C. Document the laboratory result in the client's record 129 A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. A. "I need to avoid salt in my diet." B. "It’s fine to take any over-the-counter medication with the lithium." E. “Diarrhea and muscle weakness are to be expected, and if these occur I don’t need to be concerned.” 130 A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should: B. Document the findings Correct 131 A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tellsthe client that this technique involves: D. Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening 132 A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I’m really thirsty — may I have something to drink?" Before giving the client a drink, the nurse should: B. Check for the presence of a gag reflex 133 A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority? C. Decreased fluid volume 134 A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine: D. The degree of fetal lung maturity 135 A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply. B. Potatoes C. Spinach D. Legumes E. Whole grains 136 A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside? D. Calcium gluconate 137 A nurse is monitoring a client receiving terbutaline (Brethine) by intravenous infusion to stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by the nurse is: A. Contacting the physician 138 A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that: C. Urine output must be measured and that the physician should be notified if output is less than 500 mL in a 24-hour period Correct 139 A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which items of the following information elicited during the assessment indicate that the condition has not yet resolved? Type the option number that is the correct answer. Answer: Correct Responses: "1" 140 A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client? A. Spontaneous bruising 141 A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately: A. Stops the oxytocin infusion 142. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? B) "The seizure may or may not mean your child has epilepsy." 143. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies? A) Risk for injury 144. The nurse is caring for a 10 month-old infant who is has oxygen via mask. It is important for the nurse to maintain patency of which of these areas? B) Nasal passages 145. The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client? D) "Complete all of the antibiotic even if your findings decrease." 146. When counseling a 6 year old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder? A) Has no clear etiology 147. The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior? C) Use patience and a sense of humor to deal with this behavior 148. The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following demonstrates appropriate teaching by the nurse? C) Papules, vesicles, and crusts will be present at one time 149. The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first? B) Place the client in a sitting position with legs dangling 150. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to D) Wrap the child's hand in mittens or socks to prevent scratching 151. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best? D) "A recovering person cannot return to drinking without starting the addiction process over." 152. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding? D) Uses cocaine on weekends 153. A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication? D) Thiocyanate 154. A victim of domestic violence tellsthe batterer she needs a little time away. How would the nurse expect that the batterer might respond? B) With fear of rejection causing increased rage toward the victim 155. A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus? B) Set time aside to get the mother to express her feelings and concerns 156. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client B) Use oxygen during meals improves gas exchange 157. Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? C) Mild vomiting that progressed to vomiting shooting across the room. 158. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings? B) Tissue hypoxia 159. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet A) High in carbohydrates and proteins 160. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant? C) Tripled the birth weight