2024 RN Pharmacology Exit Exam New Latest Version with All 160 Questions from Actual, Exams of Nursing

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2024 HESI RN Pharmacology Exit Exam New Latest

Version with All 160 Questions from Actual Past

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What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? ---------- Correct Answer ----------- B) Oozing liquid stool A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: ---------- Correct Answer -------- --- C) Visitors should wash their hands before and after touching the client A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? ---------- Correct Answer -- --------- Place in respiratory/secretion precautions The nurse is teaching a primigravida about preeclampsia. Which finding are indicators of preeclampsia and should be reported to the healthcare provider? (select all that apply.) ---------- Correct Answer ----------- Blurred vision Headache. swollen hands A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement? ---------- Correct Answer ------ ----- b. Direct the nurse to change the IV tubing. A client with syndrome of inappropriate antidiuretic hormone secretion (SIDH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? ---------- Correct Answer ------ ----- Initiate seizure precautions. The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900, what nursing action is most important? ---------- Correct Answer ----------- Confirm that the client has been NPO since midnight. The nurse is conducing a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately? ---------- Correct Answer ----------- d. Cloudy opacity of the crystalline lens. A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? ---------- Correct

Answer ----------- d. Assist him in identifying popular fast foods that are within his meal plan for diabetes. A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client states that he is tired of fighting his illness and is only continuing treatments because his family wants him to live. Which action should the nurse take? ---------- Correct Answer ----------- c. Ask the chaplain to discuss death issues with the client. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? ---------- Correct Answer ----------- Altered patterns of urinary elimination related to nocturia A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? ---------- Correct Answer ----------- An infant who has been identified to have botulism A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? ---------- Correct Answer ----------- D) Have gloves on while handling bedpans with feces Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? ---------- Correct Answer ----------- An elderly factory worker with a lab report that is positive for acid-fast bacillus smear A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? ---------- Correct Answer ----------- D) Contact The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? ---------- Correct Answer ----------- C) Children are not to share hats, scarves and combs. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) ---------- Correct Answer ----------- Administer a daily dose of lisinopril as scheduled. Provide a PRN dose of acetaminophen for headache An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CAV). Which interventions should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.) ---------- Correct Answer ----------- Measure neurological vital signs every 4 hours

Encourage family participate in the client's care E) Play classical music in room while client is awake A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the healthcare provider has prescribed all these medications. Which information should the nurse included when responding to this client? (Select all that apply.) ---------- Correct Answer ----------- A) One of the medications is used to anesthetize the corneal surface B) Pupillary dilation is necessary to access the eye chamber for lens removal C) The iris must be paralyzed during surgery to prevent it from reacting to light The nurse is interacting with a female client who is diagnostic with postpartum depression. Which findings should the nurse document as an objective signs of depression? (Select all that apply) ---------- Correct Answer ----------- B) Avoid eyes contact D) Has a disheveled appearance E) Interacts with felt effect A client who is hospitalized and recently diagnosed with Addison's disease is now confused and lethargic. Which actions should the nurse implement? (Select all that apply) ---------- Correct Answer ----------- A) Measure capillary glucose level B) Monitor cardiac telemetry pattern E) Initiate fall risk precautions 61 - An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? (Select all that apply) ---------- Correct Answer ----------- A) Teach client to use incentive spirometer q2 hours while awake B) Remove urinary catheter as soon as possible and encourage voiding An older adult client admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.) ---------- Correct Answer ----------- Measure neurological vital signs every 4 hours D) Encourage family to participate in the client's care E) Play classical music in room while client is awake To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client's discharge plan? (Select all that apply). ---------- Correct Answer ----------- A) Practice relaxation exercises C) Space activities to allow for rest periods D) Avoid persons with infections

142. While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? (Select all that apply). ---------- Correct Answer ----------- A) Provide supplemental oxygen B) Auscultate bilateral lung fields D) Reinforce occlusive CT dressing
143. After an explosion at a factory one of the workers approaches the nurse and says "I am an unlicensed assistive personnel (UAP) at the local hospital." Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers? ---------- Correct Answer ----------- C) Palpate pulses
144. Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? ---------- Correct Answer ----------- D) A young adult in the second day of treatment for an overdose of acetometaphen
145. The mother of a toddler who is being treated for pesticide poisoning asks: "Why is activated charcoal used? What does it do?" What is the nurse's best response? ---------- Correct Answer ----------- "The charcoal absorbs the poison and forms a compound that doesn't hurt your child."
146. The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medication the nurse should say ---------- Correct Answer ----------- B) "What is your name? What allergies do you have?" then check the client's name band and allergy band As the room is entered say
147. Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition? ---------- Correct Answer - ---------- B) A positive purified protein derivative with an abnormal chest x-ray
148. After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply) ---------- Correct Answer ----------- C) Place a small pillow under the head D) Remove resuscitation equipment from the room E) Gently close the eyes
149. A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include during the instructions

to the client is which of these statements? ---------- Correct Answer ----------- In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice.

150. The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement? ---------- Correct Answer ----------- Place client in a negative pressure private room and have all who enter the room use masks with shields
151. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN? ---------- Correct Answer ----------- C) Irrigate and redress a leg wound
152. When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because ---------- Correct Answer ----------- Normal patterns of behavior may be labeled as deviant, immoral, or insane
153. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.) ---------- Correct Answer ----------- B) Recognize signs and symptoms of hypoglycemia. Report persist polyuria to the healthcare provider Take Glucophage with the morning and evening meal.
154. After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond by saying ---------- Correct Answer ----------- C) "He is scared and taking it out on you. Let's talk to figure out what to do."
155. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements? ---------- Correct Answer ----------- D) I need to get the client's written consent before I release any information to you.
156. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that ---------- Correct Answer ----------- B) The client has a right to know about the prescribed medications
157. A nurse is administering diazepam, a benzodiazepine, 10 mg IV push PRN, as prescribed to a client with alcohol withdrawal symptoms. Which actions should the

nurse implement when administering the medication? (Select all that apply) ---------- Correct Answer ----------- B) Monitor for changes in level of consciousness D) Perform ongoing assessment of respiratory status E) Administer slowly over at least two minutes

158. A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which interventions should the nurse implement? (Select all that apply) ---------- Correct Answer ----------- A) Give the client 4 ounces of orange juice B) Obtain blood pressure and pulse rate E) Check the client's current finger stick blood glucose
159. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective sign of depression? (Select all that apply) ---------- Correct Answer ----------- A. Interacts with a flat affect B. Avoids eye contact C. Has a disheveled appearance
160. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse implement first? ---------- Correct Answer ----------- d. Increase the infusion rate of Lactated Ringer's solution.
161. an adult male who fell 20 feet from the roof of this home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). the nurse notes that the suction control chamber is bubbling at the

• 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? ---------- Correct Answer ----------- a. Add sterile water to the suction control chamber.

3. A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? ---------- Correct Answer ----------- c. Begin supplemental oxygen.
4. A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) ---------- Correct Answer ----------- Headache and tremors Irregular heart rate pallor and diaphoresis

5. An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? ---------- Correct Answer ----------- d. Skin tenting occurs when the client's forearm is pinched.
6. After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? ---------- Correct Answer ----------- a. File a detailed incident report with the specific hiring facility.
7. The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicate the program is effective? ---------- Correct Answer ----------- c. Clients who incurred disease complications promptly received rehabilitation.
8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? ---------- Correct Answer ----------- d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? ---------- Correct Answer ----------- When I get out of bed quickly, I feel a little dizzy."
10. An older adult male who is in his early 70's is admitted to the emergency department because of a COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provide the nurse a copy of the client's living will. Which action should the nurse take? ---------- Correct Answer ----------- b. Notify the healthcare provider of the client's wishes.
11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? ---------- Correct Answer ----------- c. Advice the client to maintain bedrest so that safety can be ensured.
12. A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at the parent-teacher meeting. What action is most important for the nurse to include in the meeting? ---------- Correct Answer ----------- c. Distribute a shopping list of suggested healthy snack items.

13. After several months of chronic fatigue, morning stiffness, and join pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the nurse provide the client with regard to taking prednisone? ---------- Correct Answer ----------- c. If sequential doses are missed, notify the healthcare provider.
14. The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention? ---------- Correct Answer ----------- c. An 18- year-old client with antisocial behavior who is being yelled at by other clients
15. The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms? ---------- Correct Answer ----------- b. Ear pain and fever.
16. A client arrives for an annual physical exam and complains of having calf pain. The client's health history reveals peripheral atrial disease. Which question should the nurse ask the client about expected finding related to chronic arterial symptoms? - --------- Correct Answer ----------- b. Does the calf pain occur when walking short distances?
17. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for them to explore further prior to the start of the procedure? ---------- Correct Answer ----------- d. Experience facial swelling after eating crab.
18. The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? ------- --- Correct Answer ----------- b. Apply baby lotion to the skin twice daily.
19. A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. What action should the nurse take first? ---------- Correct Answer ----------- d. Match ID bands of all infants and mothers on the unit.
20. While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask? ---------- Correct Answer ----------- c. "Have you thought about taking your life?"
21. A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "kill, kill." What question should the nurse ask the client next? ---------- Correct Answer ----------- c. "Are you planning to obey the voices?"
22. The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? ---------- Correct Answer ----------- d. The client's skin on the lower legs will be intact at the next clinical visit.

23. When conducting diet teaching for a client who was diagnosed with hypertension, which food should the nurse encourage the client to eat? (select all that apply.) ---------- Correct Answer ----------- a.. Fruits without sauce c. Fresh or frozen vegetables without sauce.
24. A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to the nurse that the client is experiencing a therapeutic response to the phenytoin? ---------- Correct Answer ----------- c. Absence of seizure activity for the duration of treatment.
25. The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? (Select all that apply) ---------- Correct Answer ----------- a. Brings a heavy can close to body before lifting. b. Locks knees while preparing food on the counter.
26. An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative indicating impaired mental status (IMS). What intervention should the nurse implement first? ---------- Correct Answer ----------- b. Reduce environmental stimuli.
27. The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)? ---------- Correct Answer ----------- Establish blood pressure parameters for client monitoring
28. During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first? ---------- Correct Answer ----------- d. A bucket of water was spilled in the hallway.
29. An older adult client with chronic emphysema is admitted to the emergency room from home with acute onset of weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview? ---------- Correct Answer ----------- Recent compliance with prescribed medications
30. The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement? ---------- Correct Answer ----------- b. Monitor the client when using a straw for liquids.
31. A male client with right-sided weakness calls for assistance with ambulating to the bathroom. What action should the nurse implement? ---------- Correct Answer ----------- b. Stand on the client's right side as he walks.

32. An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement? ---------- Correct Answer ----------- b. Ensure that the client is assigned to a room close to the nurses' station.
33. The nurse is caring for a client who is having a sickle cell crisis. What intervention should the nurse include in this client's plan of care? ---------- Correct Answer ----------- Ensure adequate IV and oral fluid intake.
34. Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing..... had a pulmonary embolus. What action should the nurse take first? ---------- Correct Answer ----------- c. Provide supplemental oxygen.
35. A client admitted with a liver abscess is scheduled for surgical evacuation and drainage of the abscess tomorrow morning. Nursing assess .... Client's abdominal pain has increased from 4 to 8 on a 10-point scale in the last four hours. What is priority nursing action? ---------- Correct Answer ----------- Notify the surgeon of increasing abdominal pain.
36. A female client with chronic kidney disease and renal failure has an indwelling peritoneal catheter in ..... used for peritoneal dialysis. While bathing, the her abdominal dressing becomes wet. What action should the nurse take? ---------- Correct Answer ----- ------ Change the dressing.
37. The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome shows a plan of care for this client? ---------- Correct Answer ----------- c. The nurse will demonstrate the procedure for accurate eye care.
38. The nurse identifies an electrolyte imbalance, an elevated pulse rate, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with chronic kidney disease. What intervention should the nurse include in the plan of care? ---------- Correct Answer - ------- --- Monitor serum electrolytes daily.
39. A client with postpartum depression, who is admitted to the behavioral health unit, refuses to leave her room or eat meals. In addition to patient's safety, which short-term goal should the nurse include in the plan of care? ---------- Correct Answer - ---------- d. Consumes 3 meals and 1500 mL of fluid per day.
40. Which information is a priority for the RN to reinforce to an older client after intravenous pyelogram? ---------- Correct Answer ----------- Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

48. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is --- ------- Correct Answer ----------- d. Weekly weight
49. A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most important for the nurse to reinforce with the client? ---------- Correct Answer --------- -- b. It is critical to report promptly to your health care provider any findings of peptic ulcers
50. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first? ---------- Correct Answer ----------- b. Have the client turn to the left side
51. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? ---------- Correct Answer ----------- A cold, pale lower leg
52. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? ---------- Correct Answer - ---------- B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
53. 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? ---------- Correct Answer ----------- A) Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.
54. 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? ---------- Correct Answer ----------- C) The flow of life is believed to flow through major pathways or nerve clusters in your body.
55. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? ---------- Correct Answer ----------- C) Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent
56. 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? ---------- Correct Answer ----------- A) Side-lying on the left with the head elevated 10 degrees
57. 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? ---------- Correct Answer ----------- minimal drainage into the urinary collection bag

58. 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? ---------- Correct Answer ----------- C) Participate with the compressions or breathing
59. 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? ------- --- Correct Answer ----------- B) Jugular vein distention
60. 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 ---------- Correct Answer ----------- Can predispose to dysrhythmias
61. 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? ---------- Correct Answer ----------- Pupils fixed and dilated
62. 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? ---------- Correct Answer ----------- D)"I went to the health care provider last week for a cold and I have gotten worse."
63. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? ---------- Correct Answer ----------- Pale mucosa of the eyelids and lips
64. 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 ---------- Correct Answer ----------- Pupil responses
65. 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? ---------- Correct Answer ----------- D) A preschooler with intermittent episodes of alertness
66. 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 ---------- Correct Answer ----------- D) Pale, thin arms and legs, uninterested in surroundings
67. 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? ---------- Correct Answer ----------- D) Hair loss

68. 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 appropriate nursing intervention is to ---------- Correct Answer ----------- Administer acetaminophen as ordered as this is normal at this time
69. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be ---------- Correct Answer ----------- B) Assess for dyspnea or stridor
70. 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? ---------- Correct Answer -------- --- I went to the bathroom and my urine looked very red and it didn't hurt when I went.
71. 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? ---------- Correct Answer ----------- Fibroids that cause no problems still need to be taken out.
72. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? ---------- Correct Answer ----------- A) Stay with client and observe for airway obstruction
73. 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? ---------- Correct Answer ----------- A) FHT 168 beats/min
74. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? ---------- Correct Answer ----------- B) "I have been coughing up foul-tasting, brown, thick sputum."
75. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal ---------- Correct Answer ----------- S ventricular gallop
76. Which of these observations made by the nurse during an excretory urogram indicate a complicaton? ---------- Correct Answer ----------- B) The client's entire body turns a bright red color

77. 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? ---------- Correct Answer ----------- "The tube will remove excess air from your chest."
78. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? ---------- Correct Answer ----------- Serum potassium 6 mEq/L
79. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? ------ ---- Correct Answer ----------- C) Dyspnea
80. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? ---------- Correct Answer ----------- C) Pulse oximetry of 88
81. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? ---------- Correct Answer ----------- D) restlessness
82. The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to ---------- Correct Answer ----------- Assist client to turn, deep breathe, and cough
83. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote ---------- Correct Answer ----------- Deep breathing and coughing
84. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? ---------- Correct Answer ----------- D) Assist with oral hygiene
85. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? ---------- Correct Answer ----------- B) Assess for post operative arrhythmias
86. A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? ---------- Correct Answer ----------- C) Lower the oxygen rate
87. A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? ---------- Correct Answer ----------- A) Notify the health care provider

88. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to ---------- Correct Answer ----------- Reinforce the dressing and elevate the leg
89. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? ---------- Correct Answer ----------- B) Leukopenia
90. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? ---------- Correct Answer ----------- Continue to monitor the rate of drainage
91. A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? ---------- Correct Answer ----------- Loss of pulse in the extremity
92. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? ---------- Correct Answer ----------- C) Assist him to stand by the side of the bed to void
93. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? ---------- Correct Answer ----------- B) Perform a quick assessment of the client's condition
94. The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? ---------- Correct Answer ----------- A) Hold the tube feeding and notify the provider
95. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must ---------- Correct Answer ----------- A) Apply suction for no more than 10 seconds
96. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to ---------- Correct Answer ----------- administer the medication in 2 separate injections

97. The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to ---------- Correct Answer ----------- D) prevent the drug from tissue irritation Skip
98. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? ---------- Correct Answer ----------- improved respiratory status and increased urinary output
99. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? ---------- Correct Answer ----------- C) "The medication must be continued so the fluid problem is controlled."
100. A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? ---------- Correct Answer ----------- B) Sore throat, fever
101. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic? ---------- Correct Answer ----------- D) No bowel movement for 3 days Skip
102. A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values? ---------- Correct Answer ----------- C) Activated PTT
103. A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? ---------- Correct Answer ----------- D) Flush adequately with water before and after using the tube
104. The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective? -- -------- Correct Answer ----------- B) "Our child should brush and floss carefully after every meal."
105. The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important? ---------- Correct Answer -------- --- Avoid chocolate and cheese
106. A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? ---------- Correct Answer ----------- D) Application of pediculicides
107. A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which

element? ---------- Correct Answer ----------- B) Potassium

108. The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? ---------- Correct Answer ----------- A) Stop the infusion
109. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? ---------- Correct Answer ----------- B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
110. A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? ---------- Correct Answer ----------- Hemoglobin and hematocrit
111. A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? ---------- Correct Answer --- -------- Protamine
112. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? ---------- Correct Answer ----------- D) "I always make sure to shake the NPH bottle hard to mix it well."
113. Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? ---------- Correct Answer ----------- Orthostatic hypotension is a common side effect
114. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? ---------- Correct Answer ----------- D) Baked potato
115. An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? ---------- Correct Answer ----------- B) Check the client's gag reflex
116. The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? ---------- Correct Answer ----------- C) Reposition every two hours
117. A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? ---------- Correct Answer ----------- A 79 year-old malnourished client on bed rest
118. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is ---------- Correct Answer ----------- Abdominal x-ray

119. The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to ---------- Correct Answer - ---------- Exercise doing weight bearing activities
120. Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? ---------- Correct Answer ----------- D) Bed in lowest position, wheels locked, place bed against wall
121. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula ---------- Correct Answer ----------- B) Continuously
122. The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID ---------- Correct Answer ------- ---- C) Laxatives
123. A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort? ---------- Correct Answer ----------- C) Keep conversations short
124. The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? ---------- Correct Answer ----- ------ B) Decreased sodium and potassium
125. A client who is hospitalized and recently is now confused and lethargic. Which actions should the nurse implement? (Select all that apply) ---------- Correct Answer ------ ----- A) Measure capillary glucose level B) Monitor cardiac telemetry pattern E) Initiate fall risk precautions