HESI LEVEL 1 PRACTICE EXAM 129 Questions with Verified Answers,100% CORRECT

HESI LEVEL 1 PRACTICE EXAM 129 Questions with Verified Answers The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10% dextrose and water at 54 ml/hour. D. Obtain a stat blood glucose level and notify the healthcare provider. - CORRECT ANSWER C A crying toddler has a blood pressure measurement of 120/70 mm Hg. What action should the nurse implement? A. Notify the healthcare provider of the measurement. B. Quiet the child and retake the blood pressure. C. Ask the parent if the child has a history of hypertension. D. Document the finding and recheck in 4 hours. - CORRECT ANSWER B The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide? A. The kidneys and renal function are not fully developed. B. Warmth promotes sleep so the infant will grow quickly. C. A large body surface area favors heat loss to the environment. D. The thick layer of subcutaneous fat is inadequate for insulation. - CORRECT ANSWER C What action by the nurse demonstrates culturally sensitive care? A. Asks permission before touching a client. B. Avoids questions about male-female relationships. C. Explains the differences between Western medical care and cultural folk remedies. D. Applies knowledge of a cultural group unless a client embraces Western customs. - CORRECT ANSWER A A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? A. Help the client to accept the final stage of life. B. Assist and support the client in establishing short-term goals. C. Encourage the client to make future plans, even if they are unrealistic. D. Instruct the client's family to focus on positive aspects of the client's life. - CORRECT ANSWER B A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment? A. "What is your daily calorie consumption?" B. "What vitamin and mineral supplements do you take?" C. "Do you feel that you are overweight?" D. "Will a clear liquid diet be okay after surgery?" - CORRECT ANSWER B The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain? A. A 10-year-old who was burned by a camp fire earlier today. B. A 70-year-old who has a postoperative infection from a surgery one week ago. C. A 23-year-old woman who sprained her knee while bicycling. D. A 55-year-old woman who has had moderate low back pain for three months. - CORRECT ANSWER D A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. - CORRECT ANSWER C In evaluating client care, which action should the nurse take first? A. Determine if the expected outcomes of care were achieved. B. Review the rationales used as the basis of nursing actions. C. Document the care plan goals that were successfully met. D. Prioritize interventions to be added to the client's plan of care. - CORRECT ANSWER A A female client asks the nurse to find someone who can translate her treatment concerns into her native language. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator. - CORRECT ANSWER D An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 mL of warm water and 5 mL of castile soap. C. Reposition in a Sims' position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level. - CORRECT ANSWER C A child with a penetrating eye injury comes to the school clinic. What action should the nurse implement? A. Remove the object impaled in the eye and then apply a regular eye patch. B. Place an ice bag over the eye until the healthcare provider is seen. C. Irrigate the affected eye copiously with a cool sterile saline solution. D. Apply a Fox shield to the affected eye and any type of patch to the other eye. - CORRECT ANSWER D When making the bed of a client who needs a bed cradle, which action should the nurse include? A. Teach the client to call for help before getting out of bed. B. Keep both the upper and lower side rails in a raised position. C. Keep the bed in the lowest position while changing the sheets. D. Drape the top sheet and covers loosely over the bed cradle. - CORRECT ANSWER D A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? A. Bradycardia. B. Increase in pulse rate. C. Peripheral vasodilation. D. Increase in cardiac output. - CORRECT ANSWER B When assessing a preschooler, which finding warrants further assessment by the nurse? A. Able to ride a tricycle. B. Talks about an imaginary friend. C. Dresses independently. D. Gains 2 pounds (0.9kg) in 12 months. - CORRECT ANSWER D The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination? A. Percussion. B. Auscultation. C. Deep palpation. D. Light palpation. - CORRECT ANSWER B The nurse is assessing a postmenopausal woman who is complaining of urinary urgency and frequency and stress incontinence. She also reports difficulty in emptying her bladder. These complaints are most likely due to which condition? A. Cystocele. B. Bladder infection. C. Pyelonephritis. D. Irritable bladder. - CORRECT ANSWER A What action should the nurse implement when adding sterile liquids to a sterile field? A. Use an outdated sterile liquid if the bottle is sealed and has not been opened. B. Consider the sterile field contaminated if it becomes wet during the procedure. C. Remove the container cap and lay it with the inside facing down on the sterile field. D. Hold the container high and pour the solution into a receptacle at the back of the sterile field. - CORRECT ANSWER B What is the best action for the nurse to take when initiating contact with a toddler for the first time? A. Ask the toddler to point to where it hurts. B. Tell the child your name and that you are the nurse. C. Call the child by name while picking up the toddler. D. Kneel in front of the toddler and speak softly to the child. - CORRECT ANSWER D A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news, and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time? A. "Your children are old enough to help you make decisions about their futures." B. "The social worker can tell you about placement alternatives for your children." C. "Tell me what you would like to see happen with your children in the future." D. "You have just received bad news, and you need some time to adjust to it." - CORRECT ANSWER C During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? A. Restatement of responses. B. Open-ended questions. C. Closed-ended questions. D. Problem-seeking responses. - CORRECT ANSWER C The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? A. Raise the bed to a comfortable working level. B. Bend the client's knee. C. Move the knee toward the chest as far as it will go. D. Cradle the client's heel. - CORRECT ANSWER D The nurse should instruct a client to avoid which product while taking carisoprodol (Soma) for muscle spasms? A. Aspirin products. B. Antacids. C. Alcoholic beverages. D. Dairy products. - CORRECT ANSWER C The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, which action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water. - CORRECT ANSWER B A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? A. Most herbs are toxic or carcinogenic and should be used only when proven effective. B. There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. C. Herbs should be obtained from manufacturers with a history of quality control of their supplements. D. Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use. - CORRECT ANSWER C A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first? A. Amount of liquid protein supplements consumed daily. B. Foods and liquids consumed during the past 24 hours. C. Usual weekly intake of milk products and red meats. D. Grains and legume combinations used by the client. - CORRECT ANSWER B An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A. Generalized dry skin. B. Localized dry skin on lower extremities. C. Red flush over entire skin surface. D. Rashes in the axillary, groin, and skin fold regions. - CORRECT ANSWER D A 6-year-old squirms and giggles when the nurse begins to palpate the abdomen. What action should the nurse implement? A. Postpone the abdominal palpation until the next examination. B. Place the child's hand under the examiner's hand while palpating. C. Touch the abdomen firmly as the child takes short, quick breaths. D. Press the abdomen with the child bearing down and holding the breath. - CORRECT ANSWER B An older client with a d ecreased percentage of lean body mass is likely to receive a prescription that is adjusted based on which pharmacokinetic process? A. Absorption. B. Metabolism. C. Elimination. D. Distribution - CORRECT ANSWER D What is the correct procedure for performing an opthalmoscopic examination on a client's right retina? A. Instruct the client to look at examiner's nose and not move his/her eyes during the exam. B. Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye. C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil. D. For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's eye. - CORRECT ANSWER C A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? A. Generativity. B. Ego integrity. C. Identification. D. Valuing wisdom. - CORRECT ANSWER A A 17-year-old male student reports to the school clinic one morning for a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assesses his vital signs: temperature 100 F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take? A. Tell the student to proceed directly to his regularly scheduled class. B. Call the parent and suggest re-taking the student's temperature at home. C. Give the student a glass of cool fluids, then retake his temperature. D. Send the student to class, but re-verify his temperature after lunch. - CORRECT ANSWER A The home health nurse is admitting a client with Parkinson's disease to the home healthcare service. In planning care for this client, which nursing diagnosis has priority? A. Impaired physical mobility related to muscle rigidity and weakness. B. Ineffective coping related to depression and dysfunction due to disease progression. C. Ineffective breathing pattern related to respiratory muscle weakness. D. Fear related to constant possibility of experiencing seizures. - CORRECT ANSWER A In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.) A. Set the infusion pump to infuse the albumin within four hours. B. Compare the client's blood type with the label on the albumin. C. Assign a UAP to monitor blood pressure q15 minutes. D. Administer through a large gauge catheter. E. Monitor hemoglobin and hematocrit levels. F. Assess for increased bleeding after administration. - CORRECT ANSWER DEF Which client assessment data is most important for the nurse to consider before ambulating a postoperative client? A. Respiratory rate. B. Wound location. C. Pedal pulses. D. Pain rating. - CORRECT ANSWER A The nurse receives a unit of blood from the blood bank for a postoperative client who is currently in the X-ray department. What action should the nurse implement? A. Return the blood to the blood bank for refrigeration within 30 minutes. B. Hang the blood transfusion as soon as the client returns to the unit. C. Store the blood bag in the nursing unit's refrigerator until the client returns. D. Take the unit of blood to the X-ray department to initiate the transfusion. - CORRECT ANSWER A To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement? A. Use a happy-face/sad-face pain scale. B. Ask the mother if she thinks the analgesic is working. C. Assess for changes in the child's vital signs. D. Teach the child to point to a numeric pain scale - CORRECT ANSWER A The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? A. Inherited familial health disorders. B. Chronic health problems. C. Reason for seeking health care. D. Undetected disorders. - CORRECT ANSWER A The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include in the dietary plan? A. Fiber. B. Folate. C. Ascorbic acid. D. Vitamin B12. - CORRECT ANSWER D An older client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube (GT). What is the best position for the client for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine. - CORRECT ANSWER B Which topic should the nurse include in planning a secondary prevention project for the local retirement community? A. Safety measures in the home. B. Adult immunization program. C. Rehabilitation after surgery. D. Vision and hearing screening. - CORRECT ANSWER D A Spanish-speaking client is scheduled for surgery in the morning and preoperative teaching needs to be completed. Since the primary care nurse speaks very little Spanish, which person is best to translate the instructions to the client? A. A Spanish-speaking UAP who has worked on the unit for many years. B. The client's husband who is an attorney at a large local law firm. C. A practical nurse working on another unit who speaks fluent Spanish. D. The primary care nurse with the help of the Spanish speaking UAP. - CORRECT ANSWER D Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention. - CORRECT ANSWER D Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation? A. Place HIV positive clients in strict isolation and limit visitors. B. Wear gloves when coming in contact with the blood or body fluids of any client. C. Conduct mandatory HIV testing of those who work with AIDS clients. D. Freeze HIV blood specimens at -70 F to kill the virus. - CORRECT ANSWER B The nurse hears short, high-pitched sounds just before the end of inspiration in the right and left lower lobes when auscultating a client's lungs. How should this finding be recorded? A. Inspiratory wheezes in both lungs. B. Crackles in the right and left lower lobes. C. Abnormal lung sounds in the bases of both lungs. D. Pleural friction rub in the right and left lower lobes. - CORRECT ANSWER B A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? A. "May I ask your daughter to help you with your personal hygiene?" B. "I will ask one of the female nurses to bathe you." C. "A staff member on the next shift will help you." D. "I will keep you draped and hand you the supplies as you need them." - CORRECT ANSWER B How should the nurse measure the length of a 14-month-old child ? A. Standing height. B. Prone recumbent position. C. Supine recumbent position. D. Side-lying position. - CORRECT ANSWER C When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity? A. A diet low in phosphates. B. Skin inspection for bruising. C. Exercise regimen, including swimming. D. Elimination of hazards to home safety. - CORRECT ANSWER D A client's IV infusion of 0.9% Sodium Chloride (normal saline) infiltrated earlier today, and approximately 500 ml of normal saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area. - CORRECT ANSWER B A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A. Healthcare provider notified of failure to collect specimens for prescribed blood studies. B. Blood specimens not collected because client no longer wants blood tests performed. C. Healthcare provider notified of client's refusal to have blood specimens collected for testing. D. Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified. - CORRECT ANSWER C How should the nurse handle linens that are soiled with incontinent feces? A. Put the soiled linens in an isolation bag, then place it in the dirty linen hamper. B. Place an isolation hamper in the client's room and discard the linens in it. C. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper. D. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room. - CORRECT ANSWER C A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide? A. "It may hurt a little because of the incision made in your throat." B. "It won't hurt because you're such a big boy." C. "It won't hurt because we put you to sleep." D. "It may hurt but we'll give you medicine to help you feel better." - CORRECT ANSWER D The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? A. Compress the flank and upper buttocks. B. Measure the client's abdominal girth. C. Gently palpate the lower abdomen. D. Apply light pressure over the shins. - CORRECT ANSWER A A client with chronic gouty arthritis takes allopurinol (Zyloprim) and experiences an acute attack of gouty arthritis. The healthcare provider prescribes concurrent low-dose colchicine. What information should the nurse provide the client that best explains the action of the colchicine? A. Acts like aspirin to relieve pain. B. Facilitates the excretion of uric acid. C. Reduces inflammation at the affected site. D. Prevents formation of uric acid crystals. - CORRECT ANSWER C A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed. - CORRECT ANSWER B A client asks the nurse to explain the meaning of a narrow therapeutic index of a medication. What information should the nurse use to answer the question? A. The onset of action for the medication occurs very quickly. B. A small margin exists between safe and toxic plasma levels. C. Bioavailability is significantly reduced by the first-pass effect. D. Minimum dosage is needed for the medication to be effective. - CORRECT ANSWER B A male client with severe orthopedic injuries following a motor vehicle collision is irritable, angry, and belittles the nurses. While a nurse is changing the dressing over a laceration, the client screams, "Don't touch me! You're so stupid that you'll make it worse!" Which intervention is best for the nurse to implement? A. Leave the room without saying a word. B. Provide information about infection prevention. C. Allow the client to change the dressing himself. D. Explain the healthcare provider's prescription. - CORRECT ANSWER B During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first? A. Use a laryngoscope to check for a foreign body lodged in the esophagus. B. Reposition the head to validate that the head is in the proper position to open the airway. C. Turn the client to the side and administer three back blows. D. Perform a finger sweep of the mouth to remove any vomitus. - CORRECT ANSWER B What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? A. Maintain in a lateral position using protective wrist and vest devices. B. Position prone with a small pillow below the diaphragm. C. Raise the head and knee gatch when lying in a supine position. D. Transfer into a wheelchair close to the nurse's station for observation. - CORRECT ANSWER B The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? A. Temperature increases from 98.8 to 99.0 F. B. Pulse rate decreases from 78 to 52 beats/min. C. Respiratory rate increases from 16 to 24 breaths/min. D. Blood pressure increases from 110/84 to 118/88 mm/Hg. - CORRECT ANSWER B The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin. - CORRECT ANSWER A The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? A. Check for a blood return. B. Reposition the client's arm. C. Remove the IV site dressing. D. Flush the lock with saline. - CORRECT ANSWER B An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day.What is the best action for the nurse to implement when assisting the client from the bed to the chair? A. Use a mechanical lift to transfer from the bed to a chair. B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. D. Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed. - CORRECT ANSWER D A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. Which action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use. - CORRECT ANSWER B A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A. Assist the ambulating client back to the bed. B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe. - CORRECT ANSWER A The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-pound box of medical supplies off the treatment room floor. What instruction should the charge nurse provide to the UAP? A. Ask another staff member for assistance. B. Request that supplies are delivered in smaller containers. C. Push the box against the wall to provide support while lifting. D. Bend at the knees when lifting heavy objects. - CORRECT ANSWER D The nurse is designing a program to control nosocomial infections on a geriatric unit of an acute care hospital. What strategy should be included in this plan? A. Do not allow those with influenza to be admitted to the unit. B. Require that all clients receive a pneumonia vaccine prior to admission. C. Ensure that sterile technique is followed when changing surgical dressings. D. Encourage clients to drink water to prevent urinary tract infections. - CORRECT ANSWER C A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A. Demonstrates loss of remote memory. B. Exhibits expressive dysphasia. C. Has a diminished attention span. D. Is disoriented to place and time. - CORRECT ANSWER D The nurse is assessing the neurovascular status of a child in Russell's traction. Which finding should the nurse report to the healthcare provider? A. Pale bluish coloration of the toes. B. Skin is warm and dry to the touch. C. Toes are wiggled upon command. D. Capillary refill less than 3 seconds. - CORRECT ANSWER A A peak and trough level must be drawn for a client receiving antibiotic therapy. What is the optimum time for the nurse to obtain the trough level? A. Sixty minutes after the antibiotic dose is administered. B. Immediately before the next antibiotic dose is given. C. When the next blood glucose level is to be checked. D. Thirty minutes before the next antibiotic dose is given. - CORRECT ANSWER B Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted. - CORRECT ANSWER C Which response by a client with a nursing diagnosis of "Spiritual distress," indicates to the nurse that a desired outcome measure has been met? A. Expresses concern about the meaning and importance of life. B. Remains angry at God for the continuation of the illness. C. Accepts that punishment from God is not related to illness. D. Refuses to participate in religious rituals that have no meaning. - CORRECT ANSWER C What client statement indicates to the nurse that the client requires assistance with bathing? A. "I wasn't able to pack a bag before I left for the hospital." B. "I don't understand why I'm so weak and tired." C. "I only bathe every other day." D. "I left my eyeglasses at home." - CORRECT ANSWER B The healthcare provider prescribes oral antifungal therapy for a client with onychomycosis. What information should the nurse tell the client? A. A single dose of the oral antifungal agent is usually sufficient to treat the infection. B. The infection is difficult to eradicate and requires prolonged therapy for 3 to 6 months. C. Complete eradicate is important because of the risk of a systemic infection. D. Prolonged therapy provides no benefit and increases the risk of adverse effects. - CORRECT ANSWER B Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing home safety hazards with the client. The nurse suggests that the edges of the steps be painted which color? A. Black. B. White. C. Light green. D. Medium yellow. - CORRECT ANSWER D The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. What recommendation should the nurse make that is most beneficial in protecting the client's joints? A. Increase the amount of calcium intake in the diet. B. Apply alternating heat and cold therapies. C. Initiate a weight-reduction diet to achieve a healthy body weight. D. Use a walker for ambulation to lessen weight-bearing on the hips. - CORRECT ANSWER C The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who is sitting in a chair at the bedside has an oral temperature of 97.2 F ( 36.4 C). Which intervention should the nurse implement? A. Document the temperature reading on the vital sign graphic sheet. B. Report the temperature to the healthcare provider immediately. C. Instruct the UAP to take the client's temperature again in 30 - CORRECT ANSWER A At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. Which is the best response to this client's silence? A. "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel." B. "Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery." C. "It is OK if you don't want to talk about your surgery. I will be available when you are ready." D. "I will ask a woman who has had a mastectomy to come by and share her experiences with you." - CORRECT ANSWER C The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. What symptoms would this client most likely exhibit? A. Loss of short-term memory, facial tics and grimaces, and constant writhing movements. B. Shuffling gait, masklike facial expression, and tremors of the head. C. Extreme muscular weakness, easy fatigability, and ptosis. D. Numbness of the extremities, loss of balance, and visual disturbances. - CORRECT ANSWER B An adult male who is a sales manager tells the nurse, "I am thinking about a job change. I don't feel like I am living up to my potential." Which of Maslow's developmental stages is the client attempting to achieve? A. Self-Actualization. B. Loving and Belonging. C. Basic Needs. D. Safety and Security. - CORRECT ANSWER A The nurse is assessing the effectiveness of high dose aspirin therapy for an 88-year-old client with arthritis. The client reports that she can't hear the nurse's questions because her ears are ringing. What action should the nurse implement? A. Refer the client to an audiologist for evaluation of her hearing. B. Advise the client that this is a common side effect of aspirin therapy. C. Notify the healthcare provider of this finding immediately. D. Ask the client to turn off her hearing aid during the exam. - CORRECT ANSWER C To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain? A. Can you describe where your pain is the most severe? B. What is your pain intensity on a scale of 1 to 10? C. Is your pain best described as aching, throbbing, or sharp? D. Which activities during a routine day are impacted by your pain? - CORRECT ANSWER D The nurse is preparing a teaching plan for a client with newly diagnosed glacoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using o ver-the-counter (OTC) medications for allergies ? A. Notify your healthcare provider if there is an increase in heart rate. B. Increase fluid intake while taking an antihistamine or decongestant. C. Avoid allergy medications that contain pseudoephedrine or phenylephrine. D. Ophthalmic lubricating drops may be used for eye dryness due to allergy medications. - CORRECT ANSWER C The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? A. Client. B. Healthcare provider. C. A family member. D. Previous medical records. - CORRECT ANSWER A The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A. The belief is held that the "evil eye" enters the child if anything cold is ingested. B. After surgery the child probably has refused all foods except broth. C. Eating broth strengthens the child's innate energy called "chi." D. "Hot" remedies restore balance after surgery, which is considered a "cold" condition. - CORRECT ANSWER D When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? A. The drainage tubing is secured over the siderail. B. The clamp on the urinary drainage bag is open. C. There are no dependent loops in the drainage tubing. D. The urinary drainage bag is attached to the bed frame. - CORRECT ANSWER B Which dosing schedule should the nurse teach the client to observe for a controlled-release oxycodone prescription? A. As needed. B. Every 12 hours. C. Every 24 hours. D. Every 4 to 6 hours - CORRECT ANSWER B What should the nurse assess last when examining a 5-year-old child? A. Heart. B. Lungs. C. Throat. D. Abdomen. - CORRECT ANSWER C A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement? A. Report the healthcare provider for the violation in aseptic technique. B. Allow the completion of the procedure. C. Ask if the glove and sterile field are contaminated. D. Identify the break in surgical asepsis and provide another set of sterile supplies. - CORRECT ANSWER D The nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.) A. Nail polish. B. Hearing aid. C. Wedding band. D. Left leg brace. E. Contact lenses. F. Partial dentures. - CORRECT ANSWER ABEF The nurse prepares 5% Dextrose Injection, USP, 1,000 ml IV to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer how many drops per minute? (Round to nearest whole number.) A. 80. B. 8. C. 21. D. 25. - CORRECT ANSWER C At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? A. At the beginning, middle, and end of the shift. B. After client priorities are identified for the development of the nursing care plan. C. At the end of the shift so full attention can be given to the client's needs. D. Immediately after the assessments are completed. - CORRECT ANSWER D The home health nurse visits an elderly female client who had a stroke three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. B. The client tells the nurse that she does not have much of an appetite today. C. The nurse notes that there are numerous scatter rugs throughout the house. D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago. - CORRECT ANSWER C A six-month-old returns from surgery with elbow restraints in place. What nursing care should be included when caring for any restrained child? A. Keep restraints on at all times. B. Remove restraints one at a time and provide range of motion exercises. C. Remove all restraints simultaneously and provide play activities. - CORRECT ANSWER B A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer? A. Osteoporosis is a progressive genetic disease with no effective treatment. B. Calcium loss from bones can be slowed by increasing calcium intake and exercise. C. Estrogen replacement therapy should be started to prevent the progression osteoporosis. D. Low-dose corticosteroid treatment effectively halts the course of osteoporosis. - CORRECT ANSWER B What activity should the nurse use in the evaluation phase of the nursing process? A. Ask a client to evaluate the nursing care provided. B. Document the nursing care plan in the progress notes. C. Determine whether a client's health problems have been alleviated. D. Examine the effectiveness of nursing interventions toward meeting client outcomes. - CORRECT ANSWER D An adult client is given a prescription for a scopolamine patch (Transderm Scop) to prevent motion sickness while on a cruise. Which information should the nurse provide to the client? A. Apply the patch at least 4 hours prior to departure. B. Change the patch every other day while on the cruise. C. Place the patch on a hairless area at the base of the skull. D. Drink no more than 2 alcoholic drinks during the cruise. - CORRECT ANSWER A What instruction should the nurse include in the discharge teaching for a client who needs to perform self-catheterization technique at home? A. Catheterize every 3 to 4 hours. B. Maintain sterile technique. C. Use the Cred maneuver before catheterization. D. Drink 500 ml of fluid within 2 hours of catheterization. - CORRECT ANSWER A A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? A. Hydrogel. B. Exudate absorber. C. Wet to moist dressing. D. Transparent adhesive film. - CORRECT ANSWER C In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? A. Elevate the head of the bed and attempt to palpate the site again. B. Document the presence and volume of the pulse palpated. C. Use a thigh cuff to measure the blood pressure in the leg. D. Record the presence of pitting edema in the inguinal area. - CORRECT ANSWER A The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8 F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement? A. Administer a PRN antihypertensive prescription. B. Provide the client with an additional blanket. C. Encourage additional fluid intake. D. Turn the client q2h. - CORRECT ANSWER D A client who is receiving the sixth unit of packed red blood cell transfusion is demonstrating signs and symptoms of a febrile, nonhemolytic reaction. What assessment finding is most important for the nurse to identify? A. Increased anxiety since the transfusion began. B. Drowsiness after receiving diphenhydramine (Benadryl). C. Complaints of feeling cold. D. Flushed skin and headache. - CORRECT ANSWER D While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? A. Advise the client to continue to bear down without holding his breath. B. Gently insert the lubricated suppository four inches into the rectum. C. Perform a digital exam to determine if a fecal impaction is present. D. Instruct the client to take slow deep breaths and stop bearing down. - CORRECT ANSWER D The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation. C. At the end of three inhalations. D. Immediately after inhalation. - CORRECT ANSWER B Miotic drug therapy for the treatment of glaucoma is based chiefly upon which physiologic action? A. Enhancing aqueous humor outflow. B. Inhibiting aqueous humor production. C. Maintaining intraocular pressure. D. Preventing extraocular infection - CORRECT ANSWER A The nurse assesses a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent nosocomial infection, which protocol should the nurse review with the rest of the staff? A. Follow contact isolation procedures. B. Wash hands after caring for the client. C. Wear gloves when providing personal care. D. Restrict pregnant staff or visitors into the room. - CORRECT ANSWER B A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care? A. Sleeping six to eight hours. B. Achieve a sense of control. C. Utilize problem solving skills. D. Increased focus of attention. - CORRECT ANSWER B A male client with obesity discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. "Be sure to have a complete physical examination before beginning your planned exercise program." B. "Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more." C. "Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class." D. "Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation." - CORRECT ANSWER A The low-birth-weight (LBW) infant requires a neutral thermal environment. What action should the nurse implement? A. Use wool blankets for covers. B. Avoid using disposable diapers. C. Maintain a high-humidity atmosphere. D. Continue cool oxygenation via a hood. - CORRECT ANSWER C A client's spouse is learning passive range-of-motion for the client's contracted shoulder. The nurse observes that the spouse is holding the client's arm above and below the elbow. Which nursing action should the nurse implement? A. Acknowledge that the spouse is supporting the arm correctly. B. Encourage the spouse to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct the spouse to grip directly over the joint for better motion. - CORRECT ANSWER A A client is receiving Dextrose 5% in Water (D5W) 1,000 ml at 75 ml/hour. The nurse hangs the bag of IV fluids at 0300. At what time, based on the 24-hour clock, should the infusion be completed? A. 1620. B. 1630. C. 0420. D. 0430. - CORRECT ANSWER A During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A. Adequate venous blood flow to the lower extremities. B. Estimated amount of body fat by an underarm skinfold. C. Degree of flexion and extension of the client's knee joint. D. Change in the circumference of the joint in centimeters. - CORRECT ANSWER C The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective findings? A. Complains of inability to empty bladder. B. Temperature of 99.8 ??F and pulse of 108. C. Post-voided residual volume of 750 ml. D. Specimen collection for culture and sensitivity. - CORRECT ANSWER A The nurse is completing the health assessment of a 79-year-old male client who denies any significant health problems. Which finding requires the most immediate follow-up assessment? A. Kyphosis with a reduction in height. B. Dilated superficial veins on both legs. C. External hemorrhoids with itching. D. Yellowish discoloration of the sclerae. - CORRECT ANSWER D A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? A. Take measures to promote as much comfort as possible. B. Report any signs of drug addiction to the nurse immediately. C. Wait until the client's pain is gone before assisting with personal care. D. This client's pain will be difficult to manage, since the cause is unknown. - CORRECT ANSWER A The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which nursing diagnosis should the nurse document for this client? A. Situational low self-esteem related to functional impairment and change in role function. B. Disabled family coping related to dissonant coping style of significant person. C. Interrupted family processes related to shift in health status of family member. D. Risk for ineffective therapeutic regimen management related to complexity of care. - CORRECT ANSWER B When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? A. Flush the lumen with the saline solution and administer the medication through the lumen. B. Determine if a PRN prescription for a thrombolytic agent is listed on the medication record. C. Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the tubing. D. Withdraw the aspirated blood into the syringe and use a new syringe to administer the medication. - CORRECT ANSWER A A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, "Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical." What response should the nurse provide first? A. Ask the nursing supervisor to meet with the students. B. Notify the student's clinical instructor of the situation. C. Ask the student if permission was obtained from the client. D. Explain that the records are hospital property and may not be removed. - CORRECT ANSWER D Which method of medication administration provides the client with the greatest first-pass effect? A. Oral. B. Sublingual. C. Intravenous. D. Subcutaneous. - CORRECT ANSWER A The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different? A. Method of insertion. B. Location of the tubes. C. Diameter of the tubes. D. Procedure for feedings. - CORRECT ANSWER A What action should the nurse implement to prevent conductive heat loss in a newborn? A. Place the infant under a radiant warming system. B. Put a blanket on the scale when weighing the infant. C. Dry the newborn with a warmed blanket. D. Position the crib away from the windows. - CORRECT ANSWER B What sign of malignant hyperthermia should the nurse assess for during the perioperative period in a child receiving general anesthesia? A. Apnea. B. Tachypnea. C. Bradycardia. D. Decreased blood pressure. - CORRECT ANSWER B The nurse is assisting an 82-year-old client to ambulate. Which is the center of gravity for an elderly person? A. Arms. B. Upper torso. C. Head. D. Feet. - CORRECT ANSWER B The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering. - CORRECT ANSWER B Which site should the nurse assess to obtain the pulse rate for a 1-year-old child? A. Radial. B. Apical. C. Carotid. D. Femoral. - CORRECT ANSWER B The nurse must prevent a 2-year-old with severe eczema on the face, neck, and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis? A. Obtain gloves for the child's hands. B. Apply finger cots on the child's fingers. C. Place elbow restraints on the child's arms. D. Apply soft restraints to the child's wrists. - CORRECT ANSWER C The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment. - CORRECT ANSWER A A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement, is at risk for developing decubitus ulcers. Which physical characteristic of aging contributes to such a risk? A. 16% increase in overall body fat. B. Reduced melanin production. C. Thinning of the skin with loss of elasticity. D. Calcium loss in the bones. - CORRECT ANSWER C Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first. - CORRECT ANSWER C