2025 HESI EXIT V3 EXAM

1. A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse? A) Explain to the client that the dentures must come out as they may get lost or broken in the operating room B) Ask the client if there are second thoughts about having the procedure C) Notify the anesthesia department and the surgeon of the client's refusal D) Ask the client if the preference would be to remove the dentures in the operating room receiving area The correct answer is D: Ask the client if the preference would be to remove the dentures in the operating room receiving area 2. The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which form of evaluation would best measure learning? A) Performance on written tests B) Responses to verbal questions C) Completion of a mailed survey D) Reported behavioral changes The correct answer is D: Reported behavioral changes 3. The nurse is planning care for an 18 month-old child. Which action should be included in the child's care? A) Hold and cuddle the child frequently B) Encourage the child to feed himself finger food C) Allow the child to walk independently on the nursing unit D) Engage the child in games with other children The correct answer is B: Encourage the child to feed himself finger food 4. A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events B) Detaching or dissociating in this way postpones painful feelings C) This conversion or transferring of a mental conflict to a physical symptom can lead to marital conflict D) To isolate the feelings in this way reduces conflict within the client and with others The correct answer is A: Such fantasies can gratify unconscious wishes or prepare for anticipated future events 5. An appropriate goal for a client with anxiety would be to A) Ventilate anxious feelings to the nurse B) Establish contact with reality C) Learn self-help techniques D) Become desensitized to past trauma The correct answer is C: Learn self-help techniques 6. While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best? A) "That's OK, its all right to skip your medication now and then." B) "I will have to call your doctor and report this." C) "Is there a reason why you don't want to take your medicine?" D) "Do you understand the consequences of refusing your prescribed treatment?" The correct answer is C: "Is there a reason why you don't want to take your medicine?" 7. While caring for a client, the nurse notes a pulsating mass in the client's peri umbilical area. Which of the following assessments is appropriate for the nurse to perform? A) Measure the length of the mass B) Auscultate the mass C) Percuss the mass D) Palpate the mass The correct answer is B: Auscultate the mass 8. A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client? A) "Good morning. Do you remember where you are?" B) "Hello. My name is Elaine Jones and I am your nurse for today." C) "How are you today? Remember, you're in the hospital." D) "Good morning. You’re in the hospital. I am your nurse Elaine Jones." The correct answer is D: "Good morning. 9. The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age? A) Formula or breast milk B) Dilute nonfat dry milk C) Warmed fruit juice D) Fluoridated tap water The correct answer is A: Formula or breast milk 10. The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children? A) Growth problems will occur if the fracture involves the periosteum B) Epiphyseal fractures often interrupt a child's normal growth pattern C) Children usually heal very quickly, so growth problems are rare D) Adequate blood supply to the bone prevents growth delay after fractures The correct answer is B: Epiphyseal fractures often interrupt a child''s normal growth pattern 11. The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)? A) April 8 B) January 15 C) February 11 D) December 23 The correct answer is D: December 23 12. When screening children for scoliosis, at what time of development would the nurse expect early signs to appear? A) Prenatally on ultrasound B) In early infancy C) When the child begins to bear weight D) During the preadolescent growth spurt The correct answer is D: During the preadolescent growth spurt 13. A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action? A) Discharge the client from home health care related to noncompliance B) Notify the health care provider of the client's failure to follow prescribed diet C) Discuss diet with the client to learn the reasons for not following the diet D) Make a referral to Meals-on-Wheels The correct answer is C: Discuss diet with client to learn the reasons for not following the diet 14. A client states, "People think I’m no good, you know what I mean?" Which of these responses would be most therapeutic? A) "Well people often take their own feelings of inadequacy out on others." B) "I think you’re good. So you see, there’s one person who likes you." C) "I’m not sure what you mean. Tell me a bit more about that." D) "Let's discuss this to see the reasons to create this impression on people?" The correct answer is C: "I’m not sure what you mean. Tell me a bit more about that." 15. A client being treated for hypertension returns to the community clinic for follow up. The client says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." Which of these is the best nursing diagnosis? A) Noncompliance related to medication side effects B) Knowledge deficit related to misunderstanding of disease state C) Defensive coping related to chronic illness D) Altered health maintenance related to occupation The correct answer is A: Noncompliance related to medication side effects 16. When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend? A) Biofeedback B) Deep breathing C) Distraction D) Imagery The correct answer is B: Deep breathing 17. When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in? A) Competitive board games with older children B) Playing with their own toys along side with other children C) Playing alone with hand held computer games D) Playing cooperatively with other preschoolers The correct answer is D: Playing cooperatively with other preschoolers 18. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding? A) Hold a rattle B) Bang two blocks C) Drink from a cup D) Wave "bye-bye" The correct answer is A: Hold a rattle 19. When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child? A) Provide a verbal explanation just prior to the surgery B) Provide the child with a booklet to read about the surgery C) Introduce the child to another child who had heart surgery 3 days ago D) Explain the surgery using a model of the heart The correct answer is D: Explain the surgery using a model of the heart 20. 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? A) Focus on the child's needs and recovery B) Explain the cause of the child's illness C) Acknowledge that early care would have been better D) Accept their feelings without judgment The correct answer is D: Accept their feelings without judgment 21. When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse? A) Record the number of stools per day B) Maintain strict intake and output records C) Sterile technique for dressing change at IV site D) Monitor for cardiac arrhythmias The correct answer is C: Sterile technique for dressing change at IV site 22. 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? A) Sero sanginous drainage from gums B) Hematemesis C) Pink frothy sputum D) Slight red color at urine The correct answer is B: Hematemesis 23. 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? A) Notify the health care provider B) Check the client's temperature C) Stop the transfusion D) Obtain a urine specimen The correct answer is C: Stop the transfusion 24. An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding episode. Which order should be questioned by the nurse? A) Passive range of motion B) Replacement of factor VIII C) Aspirin for pain management D) Immobilization splint The correct answer is C: Aspirin for pain management 25. 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? A) "Nystatin should be given 4 times a day after my baby eats." B) "I will boil the nipples and pacifiers for twenty minutes." C) "I should be taking the medication prescribed for this infection." D) "The therapy can be discontinued when the spots disappear." The correct answer is D: "The therapy can be discontinued when the spots disappear." 26. 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? A) Continue medication until findings are relieved B) Continue medication use as prescribed C) Avoid contact with children, pregnant women or immune depressed persons D) Take medication with Amphogel if epigastric distress occurs The correct answer is B: Continue medication use as prescribed 27. The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse's immediate attention? A) "I have a burning sensation when I urinate." B) "I have soreness and aching in my muscles." C) "I am itching all over." D) "I have cramping in my stomach." The correct answer is C: "I am itching all over." 28. 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? A) Risks of oral contraceptives B) Reduction in exercise program C) Avoidance of alcohol D) Cessation of smoking The correct answer is C: Avoidance of alcohol 29. 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? A) Directly on the anterior surface of the eyeball B) In the corner where the lids meet C) Under the upper lid as it is pulled upward D) In the conjunctival sac as the lower lid is pulled down The correct answer is D: In the conjunctival sac as the lower lid is pulled down 30. A depressed client is experiencing severe insomnia. The health care provider orders trazadone (Desyrel). The nurse tells the client to expect A) Improvement of acne B) Relief of insomnia C) Reduced arthritic pain D) Less nasal stuffiness The correct answer is B: Relief of insomnia 31. 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? A) Orange juice B) Regular insulin C) NPH Insulin D) Repeat blood sugar level The correct answer is B: Regular insulin 32. 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 B) Place several drops in the outer ear C) Insert cotton in the outer ear after giving medication D) Assist the child to lie on the affected side afterwards The correct answer is A: Hold the pinna up and back to instill the drops 33. 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? A) Use aseptic technique during dressing changes B) Maintain central line catheter integrity C) Monitor serum glucose levels D) Check results of liver function tests The correct answer is C: Monitor serum glucose levels 34. 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? A) Notify the health care provider immediately B) Recognize that this is a therapeutic level C) Observe the client for hematoma development D) Assess for bleeding at gums or IV sites The correct answer is B: Recognize that this is a therapeutic level 35. 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? A) "It will slow down the replication of the virus." B) "This medication will improve your child's overall health status." C) "This medication is used to prevent bacterial infections." D) "It will increase the effectiveness of the other medications your child receives." The correct answer is C: "This medication is used to prevent bacterial infections." 36. The nurse is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse's immediate attention? A) Temperature of 37.5 degrees Celsius B) Urine output of 300 cc in 4 hours C) Poor skin turgor D) Blood glucose of 350 mg/dl The correct answer is D: Blood glucose of 350 mg/dl 37. 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? A) "The inhaler can be used whenever I feel short of breath." B) "I should rinse my mouth after using the inhaler." C) "If I forget a dose, I can double up on the next dose." D) I should not use a spacer with my Azmacort. The correct answer is B: "I should rinse my mouth after using the inhaler." 38. 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 B) Confusion C) Blood in the urine D) Tinnitis The correct answer is A: Muscle weakness and cramping 39. 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 B) Daily intake of potassium C) Activity and rest patterns D) Baseline heart rate Review Information: The correct answer is A: Schedule for taking medicine 40. Which of the following classifications of medications would be most often used for clients with schizophrenia? A) Anti-depressants B) Mood stabilizers C) Anxiolytics D) Neuroleptics The correct answer is D: Neuroleptics 41. A hospitalized 8 month-old infant is receiving digoxin for the treatment of Tetralogy of Fallot. Prior to administering the next dose of medication, the parent reports that the baby has vomited one time, just after breakfast. The heart rate is 62. What is the initial response of the nurse? A) Give the dose after lunch B) Reduce the next dose by half C) Double the next dose * D) Hold the medication The correct answer is D: Hold the medication 42. A child is treated with edetate calcium disodium (Calcium EDTA) for lead poisoning. Which of these should the nurse assess first ? A) Serum potassium level B) Blood calcium level C) Urinary output D) Deep tendon reflexes The correct answer is C: Urinary output 43. The nurse is assessing a client who has taken haldol (Haloperidol) for several months. Which of the following is a side effect of this medication and must be reported immediately to the health care provider? A) Muscle flaccidity B) Dystonic reaction C) Mood swings D) Dry, harsh cough The correct answer is B: Dystonic reaction 44. The nurse is caring for a client with renal calculi. Which health care provider order would be a priority? A) Morphine sulfate as client controlled analgesia B) Push oral fluids and keep vein open C) Continuous warm compresses to the flank area D) Intravenous antibiotics The correct answer is A: Morphine sulfate as client controlled analgesia 45. A client with angina has been instructed about the use of sublingual nitroglycerin. Which of the following statements made to the nurse indicates a need for further teaching? A) "I will rest briefly right after taking 1 tablet." B) "I can take 2-3 tablets at once if I have severe pain." C) "I'll call the doctor if pain continues after 3 tablets 5 minutes apart." D) "I understand that the medication should be kept in the dark bottle." The correct answer is B: "I can take 2-3 tablets at once if I have severe pain." 46. The nurse is teaching administration of albuterol inhalation to an adult with asthma. Which of the following demonstrates proper teaching? A) "Use this medication at bedtime to promote rest." B) "Discontinue the inhalation if you are dizzy." C) "Inhale this medication after other asthma sprays." D) "Notify the health care provider if you need the drug more often." The correct answer is D: "Notify the health care provider if you need the drug more often." 47. A hospitalized 8 month-old is receiving gentamicin (Cidomycin). In monitoring the infant for drug toxicity, the nurse should review which laboratory results first? A) Blood urea nitrogen B) Thyroxin levels C) Growth hormone levels D) Platelet counts The correct answer is A: Blood urea nitrogen 48. A client who is receiving chemotherapy through a central line is admitted to the hospital with a diagnosis of sepsis. Which of the following nursing interventions should receive priority? A) Inspect all sites that may serve as entry ports for bacteria B) Place the client in reverse isolation C) Change the dressing over the site of the central line D) Restrict contact with persons having known, or recent, infections The correct answer is A: Inspect all sites that may serve as entry ports for bacteria 49. The nurse is caring for a client with Parkinson's disease who has developed hallucinations. Which of the following medications that the client is receiving may have been a contributing factor? A) L-Dopa B) Cogentin C) Baclofen D) Benadryl The correct answer is A: L-Dopa 50. The nurse is caring for a child receiving albuterol (Proventil) for asthma. The parents ask the nurse why their child is receiving this medication. Which explanation is correct? A) decrease the swelling in the airways." * B) relax the smooth muscles in the airways." C) reduce the secretions blocking the airways." D) stimulate the respiratory center in the brain that control respirations." The correct answer is B: relax the smooth muscles in the airways." 51. The nurse prepares to give a one year-old child an intramuscular injection. Where is the best site for this injection? A) Deltoid muscle B) Ventrogluteal muscle C) Dorsogluteal muscle D) Vastus lateralis muscle The correct answer is D: Vastus lateralis muscle 52. The nurse is administering albuterol (Proventil) to a child with asthma. Which of the following assessments by the nurse indicate the need for an adjustment of the medication? A) Lethargy and fatigue B) Edema is the lower extremities C) Apical Pulse of 112 D) Temperature of 101 degrees Fahrenheit The correct answer is C: Apical Pulse of 112 53. To which of the following nursing home residents could the nurse safely administer tricyclic antidepressants without questioning the health care provider's order? A) An 85 year-old male with narrow-angle glaucoma B) An African-American with benign prostatic hypertrophy C) A 65 year-old female with mild hypertension D) A Hispanic female with coronary artery disease The correct answer is C: A 65 year-old female with mild hypertension 54. The nurse is teaching a client about precautions with Coumadin. The nurse should instruct the client to avoid foods with excessive amounts of which nutrient A) Calcium B) Vitamin K C) Iron D) Vitamin E The correct answer is B: Vitamin K 55. The nurse is caring for a 15 month-old child with a first episode of otitis media. Which of the following interventions should the nurse include in instructions to the child's parents? A) Explain that the child should complete the full 5 days of antibiotics B) Provide them with handout describing care of myringotomy tubes C) Describe the tympanocentesis to detect persistent infections D) Emphasize the importance of a return visit after completion of antibiotics The correct answer is D: Emphasize the importance of a return visit after completion of antibiotics 56. The nurse is caring for an 81 year-old client with colorectal cancer. The client's pain has been managed until now with acetaminophen with codeine. Because of increased pain, intravenous morphine is added. What should the nurse recognize about the validity of this order? A) Inappropriate because of potential respiratory depression B) Appropriate despite the expected effect of mental confusion C) Inappropriate and demonstrates poor knowledge of pain control D) Appropriate pain management around-the-clock The correct answer is D: Appropriate pain management around-the-clock 57. Before administering digoxin (Lanoxin) to a client, which of the following nursing assessments is a priority? A) Auscultate breath sounds B) Check for bowel sounds C) Monitor the heart rate D) Measure the blood pressure The correct answer is C: Monitor the heart rate 58. When teaching a client about the use of sublingual nitroglycerin, the nurse should emphasize that which of these is the most common side effect? A) Headache B) Dry mouth C) Depression D) Anorexia The correct answer is A: Headache 59. What would the nurse expect to see in a client who is experiencing symptoms of tardive dyskinesia? A) Rapid tongue movements B) Uncontrolled hand tremors during meals C) Behavioral changes D) Repetitive slapping movements The correct answer is A: Rapid tongue movements 60. The nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which of the following must be emphasized? A) Rest in bed for an hour after taking medication B) Take the medication at the same time each day C) Keep the medication bottle in the refrigerator D) Carry the nitroglycerine with you at all times The correct answer is D: Carry the nitroglycerine with you at all times 61. The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client? A) Ask the client and family if they are satisfied with the care given B) Determine if the home health aide's care is consistent with the plan of care C) Investigate if the home health aide is prompt and stays an appropriate length of time for care D) Check the documentation of the aide for appropriateness and comprehensiveness The correct answer is B: Determine if the home health aide is following the plan of care 62. The nurse in the same day surgery unit assigns the unlicensed assistive personnel (UAP) to give a 1000 ml soap solution enema (SSE) to a client scheduled for an abdominal hysterectomy. Which statement by the nurse is most appropriate? A) "Administer enemas until the results are clear." B) "Give 3 enemas before surgery." C) "Let me know the results of the enema." D) "Slow the flow of the solution if cramping occurs." The correct answer is D: "Slow the flow of the solution if cramping occurs." 63. An RN from the women’s health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse? A) A newly diagnosed client with type 2 diabetes mellitus who is learning foot care B) A client from a motor vehicle accident with an external fixation device on the leg C) A client admitted for a barium swallow after a transient ischemic attack D) A newly admitted client with a diagnosis of pancreatic cancer The correct answer is B: A motor vehicle accident (MVA) client with an external fixation device on the leg 64. Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items? A) The client has complaints of not sleeping well for the past week. B) The family wants to discontinue the home meal service, meals on wheels. C) The urine in the urinary catheter bag is of a deeper amber, almost brown color. D) The partner says the client has slower days every other day. The correct answer is C: The urine in the urinary catheter bag is of a deeper amber almost brown color. 65. A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)? A) Ask the client the degree of relief and document the client’s response B) Decrease the set rate on the pump by 2 ml/minute C) Check the IV site for drainage and loose tape D) Assist the client with ambulation and a gown change The correct answer is D: Assist the client with ambulation and a gown change 66. A practical nurse (PN) from the pediatric unit is assigned to work in a critical care unit. Which client assignment would be appropriate? A) A client admitted with multiple trauma with a history of a newly implanted pacemaker B) A new admission with left-sided weakness from a stroke and mild confusion C) A 53 year-old client diagnosed with cardiac arrest from a suspected myocardial infarction D) A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident The correct answer is D: A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident 67. A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which o staff members should the charge nurse assign the client? A) Unlicensed assistive personnel (UAP) B) Senior nursing student C) PN D) RN The correct answer is D: An RN 68. Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to ambulate a client for the first time after a colon resection? A) "Have the client sit on the side of the bed before helping the client to walk." B) "If the client is dizzy ask the client to take some slow, deep breaths." C) "Help the client to walk in the room as often as the client wishes." D) "When you help the client to walk, ask if any pain occurs." The correct answer is A: "Have the client sit on the side of the bed before helping him/her to walk." 69. A charge nurse working in a long term care facility is making out assignments. Which assignment to an unlicensed assistive personnel (UAP), if made by the nurse, requires intervention by the supervisor? A) Provide decubitus ulcer care and apply a dry dressing B) Bathe and feed a client on bed rest C) Oral suctioning of an unresponsive elderly client D) Teaching a family intermittent (bolus) feedings via G-tube before discharge The correct answer is D: Teaching a family intermittent (bolus) feedings via G-tube before discharge 70. Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)? A) Document skin turgor and color changes B) Test stool for occult blood and urine for glucose C) Suggest foods high in iron and those easily consumed D) Report mental status changes and the degree of mental clarity The correct answer is B: Test stool for occult blood and urine for glucose 71. Which one of these tasks can be safely delegated to a PN? A) Assess the function of a newly created ileostomy B) Care for a client with a recent complicated double barrel colostomy C) Provide stoma care for a client with a well functioning ostomy D) Teach ostomy care to a client and their family members The correct answer is C: Provide stoma care for a client with a well functioning ostomy. 72. The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP? A) Report signs of redness overlying a joint B) Monitor the client's response to ambulatory activity C) Encouragement for the independence in self-care D) Assist the client to transfer from a bed to a chair The correct answer is B: Monitor the client''s response to ambulatory activity 73. Which of these clients would be most appropriate to assign to a PN? A) A trauma victim with quadriplegia and a client 1 day post-op radical neck dissection B) A client with newly diagnosed type 2 diabetes mellitus and a client with a history of AIDS admitted for pneumonia C) A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation D) A client with a history of schizophrenia in alcohol withdrawal and a client with chronic renal failure The correct answer is C: A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation. 74. A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)? A) Teach the client how to cough up secretions B) Changes the tracheostomy trach ties C) Monitor if client has shortness of breath D) Perform routine tracheostomy dressing care The correct answer is D: Perform routine tracheostomy dressing care 75. Which of these clients would be appropriate to assign to a PN? A) A trauma victim with multiple lacerations and requires complex dressings. B) An elderly client with cystitis and an indwelling urethral catheter. C) A confused client whose family complains about the nursing care 2 days after surgery. D) A client admitted for possible transient ischemic attack with unstable neuro signs. The correct answer is B: An elderly client with cystitis and an indwelling urethral catheter. 76. Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP? A) Assist with plans for any clients discharged B) Provide basic hygiene care to all clients on the unit C) Assess a client after an acute myocardial infarction D) Gather the vital signs of all clients on the unit The correct answer is B: Provide basic hygiene care to all clients on the unit 77. During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence? A) What degree of supervision for basic care do you think you need? B) Let’s review your skills check-list for type and level of skill. C) Are you comfortable working independently? D) What client care tasks or assignments do you prefer? The correct answer is B: Let’s review your skills check-list for type and level of skill. 78. An unlicensed assistive personnel (UAP), who usually works in pediatrics is assigned to work on a medical-surgical unit. Which one of the questions by the charge nurse would be most appropriate prior to making delegation decisions? A) "How long have you been a UAP?” B) "What type of care did you give in pediatrics?” C) "Do you have your competency checklist that we can review?” D) "How comfortable are you to care for adult clients?” The correct answer is C: "Do you have your competency checklist that we can review?” 79. The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to? A) Practical nurse (PN) B) Registered Nurse (RN) C) Unlicensed assistive personnel (UAP) D) Volunteer The correct answer is C: Unlicensed assistive personnel (UAP) 80. The RN delegates the task of taking vital signs of all the clients on the medicalsurgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client’s blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client’s left arm. Which of these statements is most accurate? A) The RN is accountable for this situation. B) The RN did not delegate appropriately. C) The UAP is covered by the RN’s license. D) The UAP is responsible for following instructions. The correct answer is D: The UAP is responsible for following instructions. 81. As the RN responsible for a client in isolation, which can be delegated to the PN? A) Reinforcement of isolation precautions B) Assessment of the client's attitude about infection control C) Evaluation of staffs' compliance with control measures D) Observation of the client's total environment for risks The correct answer is A: Reinforcement of isolation precautions 82. The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)? A) A client with peripheral vascular disease and an ulceration of the lower leg. B) A pre-operative client awaiting adrenalectomy with a history of asthma C) An elderly client with hypertension and self-reported noncompliance D) A new admission with a history of transient ischemic attacks and dizziness The correct answer is A: A client with peripheral vascular disease and an ulceration of the lower leg. 83. The charge nurse on a cardiac step-down unit makes assignments for the team consisting of an RN, a PN, and an unlicensed assistive person. Which client should be assigned to the PN? A) A 49 year-old with new onset atrial fibrillation with a rapid ventricular response B) A 58 year-old hypertensive with possible angina. C) A 35 year-old scheduled for cardiac catheterization. D) A 65 year-old for discharge after angioplasty and stent placement. The correct answer is B: A 58 year-old hypertensive with possible angina. 84. When walking past a client’s room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention? A) "If we work together we can get all of the client care completed." B) "Since I am late for lunch, would you do this one client's glucose test?" C) "This client seems confused, we need to watch monitor closely." D) "I’ll come back and make the bed after I go to the lab." The correct answer is B: "Since I am late for lunch, would you do this one client''s glucose test?" 85. A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements? A) I will arrange for a conference with you and the UAP within the next week. B) I can assure you that I will look into the matter. C) I would like for you to approach the UAP about the problem the next time it occurs. D) I will add this concern to the agenda for the next unit meeting. The correct answer is C: Suggest that the nurse approach the assistant about the problem 86. A client experiences intense anxiety after the home was destroyed by a fire. The client escaped from the fire with only minor injuries. The nurse knows that the most important initial intervention would be to: A) Suggest the client rent an apartment with a sprinkler system B) Provide a brochure on methods to promote relaxation. C) Determine available community and personal resources D) Explore the feelings of grief associated with the loss The correct answer is C: Determine available community and personal resources