Comprehensive HESI Exam Preparation, Exams of Nursing

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COMPREHENSIVE HESI EXAM ACCURATE

QUESSTIONS WITH VERIFIED ANSWERS

GUARANTEED PASS GRADED A

The nurse is planning a teaching program about prenatal care for a diverse ethnic group of clients. Which factor is most influential for the acceptance of the healthcare practices? a. Income grouping. b. Ethic background. c. Individual beliefs. d. Educational level. - Ans - C A low potassium diet is prescribed for a client. What foods should the nurse teach this client to avoid? a. Dried prunes. b. Cottage cheese. c. Mashed potatoes. d. Mustard greens. - Ans - A A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission? a. Administer thiamine (B1) to prevent Korsakoff's syndrome. b. Monitor for increased blood pressure and pulse. c. Administer a PRN benzodiazepine as needed for anxiety. d. Encourage fluid intake of non-caffeinated beverages. - Ans - B A client is brought into the emergency department following a sudden cardiac arrest. A full code is started. Five minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take? a. Stop the code immediately. b. Continue the code according to protocol. c. Ask the legal department if the code should be continued. d. Assess the family's support for the durable power of attorney. - Ans - A A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent? a. Instruct the client sign the consent before giving medications. b. Obtain the permission of the custodial parent for the surgery.

c. Obtain the signature of the client's stepfather for the surgery. d. Notify the non-custodial parent to also sign a consent form. - Ans - B A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client? a. Left supine with thighs flexed on her abdomen. b. Right lateral side with both legs flexed. c. Semi-Fowler's with head of bed elevated 30 degrees. d. Supine with the foot of the bed elevated. - Ans - D A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client? a. The nurse who is caring for another client receiving intracavitary radiation. b. A nurse with Marfan's syndrome who is postmenopausal. c. A nurse with oncology experience who may be pregnant. d. The nurse who is caring for another client who has Clostridium difficile. - Ans - B Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer? a. Notify the healthcare provider if heavy vaginal discharge occurs. b. Use condoms for sexual intercourse during the next week. c. Flat subclinical mucosal lesions are a common harmless side effect. d. Use a sanitary napkin instead of a tampon. - Ans – D

70. A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? A) A report of 10 pounds weight loss in the last month B) A comment by the client "I just can't sit still." C) The appearance of eyeballs that appear to "pop" out of the client's eye sockets D) A report of the sudden onset of irritability in the past 2 weeks - C The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? A.Suctions oral secretions from mouth B.Positions head of bed flat when changing sheets C.Takes temperature using the axillary method D.Keeps head of bed elevated at 30 degrees - B Rationale: Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D).

When caring for a postsurgical client who has undergone multiple blood transfusions, which serum laboratory finding is of most concern to the nurse? A.Sodium level, 137 mEq/L B.Potassium level, 5.5 mEq/L C.Blood urea nitrogen (BUN) level, 18 mg/dL D.Calcium level, 10 mEq/L - B Rationale: Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D). Which vaccination should the nurse administer to a newborn? A.Hepatitis B B.Human papilloma virus (HPV) C.Varicella D.Meningococcal vaccine - A Rationale: The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is not recommended until adolescence (B). Varicella immunization begins at 12 months (C). Meningococcal vaccine is administered beginning at 2 years (D). The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)? A.Assess the need to change a central line dressing. B.Obtain a fingerstick blood glucose level. C.Answer a family member's questions about the client's plan of care. D.Teach the client side effects to report related to the current medication regimen. - B Rationale: Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP. The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function? a. Unequal pupils. b. Loss of central reflexes. c. Inability to open the eyes. d. Change in level of consciousness. - Ans - D A nurse is planning to teach self-care measures to a female client about prevention of yeast infections. Which instructions should the nurse provide? a. Use a douche preparation no more than once a month. b. Increase daily intake of fiber and leafy green vegetables. c. Select nylon underwear that is loose-fitting, white, and comfortable. d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts. - Ans - D

A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement? a. Place an isolation cart in the hallway. b. Fit the client with a respirator mask. c. Don a clean gown for client care. d. Assign the client to a negative air-flow room. - Ans - D The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands? a. A pregnant woman. b. A teenager beginning puberty. c. A 3-month-old infant. d. A school-aged child. - Ans - A What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period? a. Team nursing. b. Primary nursing. c. Case management. d. Functional nursing. - Ans - B Which approach should the nurse use when preparing a toddler for a procedure? a. Demonstrate the procedure using a doll. b. Avoid asking the child to make choices. c. Plan a teaching session to last about 20 minutes. d. Show equipment but prevent child from handling it. - Ans - A The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requests information about the client's status. Which standard of nursing practice should the nurse use to respond? a. Caring. b. Veracity. c. Advocacy. d. Confidentiality. - Ans - D A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. What intervention should the nurse implement? a. Remove the client from the table and have him sit alone. b. Send the client back to his room and do not allow him to eat.

c. Report the behavior to the on-call psychologist immediately. d. Confront the client about the consequences of the behavior. - Ans - D Which information should the nurse give a client with chronic kidney disease (CKD)? a. Restrict calcium-rich foods. b. Obtain monthly B12 injections. c. Avoid salt substitutes. d. Increase daily intake of fiber. - Ans - C The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder? a. Grave's disease. b. Cushing syndrome. c. Multiple sclerosis. d. Addison's disease. - Ans - A A young adult female arrives at the emergency department with a black right eye and is bleeding from the left side of her head. She reports that her boyfriend has been abusing her physically. The nurse performs a history and physical examination. How should the nurse document these findings? a. Client alleges that her boyfriend beat her up. Client is bleeding from the left side of the face. b. Client reports her boyfriend hit her in the eye and on the head. Bruises and lacerations present on face. c. Client presents with a right black eye and a cut on the left side of her head that is bleeding. Reports abusive boyfriend responsible for injuries. Needs referral to a safe place to stay. d. Young adult female presents with periorbital ecchymosis on right side, 3 cm laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is abusive. - Ans - D A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing intervention is most important to include in the client's plan of care? a. Teach that anger will subside after two weeks on antidepressants. b. Ask client to describe triggers of anger. c. Gather more data about social support. d. Collaborate with the treatment team about revising the goal. - Ans - B The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, "Imbalanced nutrition: more than body requirements?" a. Morbidly obese.

b. Markedly obese. c. Inadequate lifestyle changes in diet and exercise. d. Increased morbidity and mortality risks. - Ans - C A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 ml for the first 10 kg of body weight, plus 50 ml/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the nearest whole number.) - Ans - 61 A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture? a. Asymmetry of the face and eye movements. b. Abnormal position and movement of the arm. c. Hematemesis and abdominal distention. d. Rhinorrhoea or otorrhoea with Halo sign - Ans - D The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding? a. Purplish-red pinpoint lesions of the skin. b. Purple to bluish discoloration of the skin. c. Small circumscribed elevations containing purulent fluid. d. Generalized reddish discoloration of an area of skin. - Ans - A A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next? a. Notify the healthcare provider. b. Measure the blood pressure. c. Administer the medication. d. Reassess the apical pulse. - Ans - C The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide? a. Adolescents who demonstrate labile behaviors are at risk for self-injury. b. Rebelliousness requires consequences to prevent socially deviant behavior. c. Early adolescence is a developmental stage of normal experimentation. d. The parents should consider hospitalization to prevent self injury. - Ans - C

The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding? a. Ptosis on the left eyelid. b. A nystagmus on the left. c. Astigmatism on the right. d. Exophthalmos on the right. - Ans - A The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 ml of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome? a. Demonstrates adequate fluid intake and output. b. Voids at least 1000 ml between 7am and 3 pm. c. Verbalizes abdominal comfort without pressure. d. Drinks 240 ml of fluid five times during the shift. - Ans - D The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement? a. Administer the dose as prescribed. b. Withhold the drug and notify the healthcare provider. c. Give intravenous (IV) calcium gluconate. d. Recheck the vital signs in 30 minutes and then administer the dose. - Ans - A A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor? a. Liver. b. Kidney. c. Sensory. d. Cardiorespiratory. - Ans - A A client with chronic osteomyelitis is scheduled for surgery to treat the infection which has not responded to three months of intravenous antibiotic therapy. The client asks the nurse why surgery is necessary. Which is the best response for the nurse to provide? a. The dead bone needs to be removed to provide a blood supply for new bone growth. b. The infection is caused by a mutated bacteria that is resistant to most antibiotics. c. If the infected dead bone is not removed, it will make a path to the skin and drain pus. d. The infection has walled off into an area of infected bone creating a barrier to antibiotics. - Ans - D Two hours after the vaginal delivery of a 7-pound, 3-ounce infant, a client's fundus is 3 cm above the umbilicus, boggy, and located to the right of midline. Which action should the nurse take first? a. Massage the uterine fundus. b. Palpate above the symphysis for the bladder.

c. Perform bi-manual massage. d. Inspect the perineum for excessive bleeding. - Ans - B After one month of short-term corticosteroid therapy, a client with an acute exacerbation of rheumatoid arthritis returns to the clinic for a follow-up visit. Which laboratory finding should the nurse review for a therapeutic response? a. Fasting serum glucose. b. Serum liver function test. c. Serum electrolyte levels. d. Erythrocyte sedimentation rate. - Ans - D The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction? a. "Addicts who use illegal drugs are trying to escape reality." b. "Addiction causes people to steal and lie." c. "Those who are unhappy with themselves are more likely to become addicts." d. "Wanting the drug is all that matters to an addict." - Ans - D A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing with a wet-to-dry dressing. The PN tells the nurse that she has never performed a wound packing. Which intervention should the charge nurse implement? a. Perform the wound care and have the PN provide the client's morning care. b. Advise the PN to review the procedure in the procedure manual and then complete the wound care. c. Note the PN's learning need to perform a wound packing and contact nursing education to schedule a time for instruction. d. Demonstrate the wound care procedure to the PN while the PN assists. - Ans - D Which finding should the nurse identify as an early clinical manifestation of neonatal encephalopathy related to hyperbilirubinemia? a. Mental retardation. b. Rigid extension of all extremities. c. Lethargy or irritability. d. Increased or unstable temperature. - Ans - C Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict? a. Deal with issues and not personalities. b. Require the UAPs to reach a compromise. c. Weigh the consequences of each possible solution. d. Encourage the two to view the humor of the conflict. - Ans - A

A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan? a. Apply warm compresses to reduce swelling. b. Wear sunglasses to protect eyes from sunlight. c. Take acetaminophen (Tylenol) for any eye discomfort. d. Avoid sharing towels and washcloths with siblings. - Ans - D The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema? a. History of inflammatory bowel disorders. b. Reason for administering the enema. c. Feelings about having an enema. d. Allergies to medications. - Ans - A The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace which her healthcare provider has prescribed. Which instruction would be accurate? a. Remove the brace one hour each day for bathing only. b. Remove the brace twice daily for back range of motion exercises. c. Wear the brace against the bare skin. d. Wear the brace in order to cure the spinal curvature. - Ans - A The clinic nurse identifies an elevation in the results of the triple marker screening test for a client who is in the first trimester of pregnancy. Which action should the nurse prepare the client for? a. Repeating the triple marker test. b. Preparing for other diagnostic testing. c. Counseling about possible fetal defects. d. Securing permission for pregnancy termination. - Ans - B The nurse is caring for critically ill clients. Which client should be monitored for the development of neurogenic shock? a. Heart failure. b. Gastrointestinal hemorrhage. c. Spinal cord injury. d. Diabetes insipidus. - Ans - C Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa0 2 95 mmHg and PaC0 2 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time? a. Increase the oxygen flow to 6 liters/minute. b. Encourage the use of an incentive spirometer. c. Notify the healthcare provider of the crisis blood gas values. d. Encourage the client to breathe slower. - Ans - B

Clinical portfolios are being introduced into the performance appraisal process for staff nurses employed at a hospital. What should the nurse-manager request that each staff nurse include in the portfolio? a. Evaluations by past nursing faculty and employers to document ongoing competence. b. Copies of any articles the nurse has read that relate to client care on the nursing unit. c. Letters of support from family members and friends who are healthcare professionals. d. A self-evaluation that identifies how the nurse has met professional objectives and goals. - Ans - D The nurse is teaching staff in a long-term facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension? a. "Clients with an elevated blood pressure often exhibit a stiff neck and are diaphoretic." b. "As long as clients receive daily antihypertensive medications, no further interventions are needed." c. "Caregivers should only conduct blood pressure checks under a registered nurse's direct supervision." d. "Frequent blood pressure checks, including readings taken by automated machines, are recommended." - Ans - D An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client? a. Insulin. b. Antacids. c. Tricyclic antidepressants. d. Nonsteroidal antiinflammatory agents. - Ans - C A client with osteoarthritis is given a new prescription for a nonsteroidal antiinflammatory drug (NSAID). The client asks the nurse, "How is this medication different from the acetaminophen I have been taking?" Which information about the therapeutic action of NSAIDs should the nurse provide? a. Are less expensive. b. Provide antiinflammatory response. c. Cause gastrointestinal bleeding. d. Increase hepatotoxic side effects. - Ans - B To assess a client's pupillary response to accommodation, a nurse should perform which activity? a. Cover one eye for one minute and note the pupil reaction when the cover is removed. b. Shine a light into the client's eye and watch the pupil response in the opposite eye. c. Touch the cornea with a piece of sterile cotton and observe for a change in pupil size.

d. Ask the client to look at a distant object and then at an object held 10 cm from the nose. - Ans - D A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care? a. Two acute illnesses. b. Two chronic illnesses. c. One chronic and one acute illness. d. One acute and one infectious illness. - Ans - C The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem? a. Activity intolerance related to postoperative pain. b. Noncompliance with prescribed exercise plan. c. Ineffective management of treatment regimen. d. Knowledge deficit regarding impending surgery. - Ans - A A nurse takes a female client to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states, "I have special undergarments that I do not remove for religious reasons." How should the nurse respond? a. "I will ask the healthcare provider to modify the examination." b. "All clothing must be removed before the examination to provide full access to the area to be assessed." c. "What type of undergarments are you wearing?" d. "Tell me about your undergarments so we can discuss how you can have your examination comfortably." - Ans - D A male client who lives in an area endemic with Lyme disease asks the nurse what to do if he thinks he may have been exposed. Which response should the nurse provide? a. Cover the ticks with oil to suffocate and kill them to prevent transmission. b. Look for early signs of a lesion that increases in size with a red border, clear center. c. See a healthcare provider if nausea, vomiting, and joint pain occur after a tick bite. d. Obtain early treatment with antiviral agents to prevent cardiac manifestations. - Ans - B The nurse dons gown, mask with eyeshield, and gloves before entering a client's room that has airborne precautions. Upon leaving the client's room, in which sequence should the nurse remove the personal protective equipment (PPE)? (Place the first action on top and last action on the bottom.) a. Wash hands. b. Remove mask. c. Remove gown. d. Remove gloves. - Ans - D, C, B, A

The nurse is planning care for a client who is having abdominal surgery. To achieve desired postoperative outcomes, the nurse includes interventions that promote progressive mobilization, such as turn, cough, deep breathe, and early ambulation. Which additional intervention should the nurse include? a. Explain the rationale for each postoperative exercise and intervention. b. Praise client when actively participating in postoperative exercises. c. Administer analgesics prior to encouraging progressive activities and ambulation. d. Advise client about complications related to inactivity in the postoperative period. - Ans - C A client is admitted with a medical diagnosis of Addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations? a. Thin, fragile skin, ecchymoses, and complaints of weakness. b. Headache, diaphoresis, and palpitations. c. Hypotension, rapid weak pulse, and rapid respiratory rate. d. Abrupt onset of hyperpyrexia, extreme tachycardia, and delirium. - Ans - C During a well-woman exam, a sexually active female client asks the nurse about a recent vaginal infection and says she is afraid she has another sexually transmitted infection (STI). The client discloses her history of previous STI. Which condition should the nurse identify as the most prevalent STI in the United States among women? a. Gonorrhea. b. Chlamydia. c. Candidiasis. d. Trichomoniasis. - Ans - B Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess? a. Ability to grasp objects. b. Ability to bear weight. c. Upper body muscle strength. d. Tolerance of exertion. - Ans - D The nurse is planning a wellness program aimed at primary prevention in the community. Which action should the nurse implement? a. Immunizations that decrease occurrences of many contagious diseases. b. Blood pressure screenings to identify persons with high blood pressure. c. Breast self-examination (BSE) for young women instead of a mammogram. d. Home care monitoring for clients who are high-risk due to pregnancy. - Ans - A A work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to be most effective in developing the new care map?

a. Nurse-manager group. b. Multidisciplinary group. c. Single-discipline group. d. Surgical staff group. - Ans - B A female client tells the nurse that she does not know which day of the month is best to do breast self-exams (BSE). Which instruction should the nurse provide? a. Midway between menstrual cycles. b. One week before your period. c. The first day of your period. d. Five to seven days after menses cease. - Ans - D Prior to the discharge of a healthy 4-day-old newborn, the nurse is collecting the blood specimens to screen for phenylketonuria (PKU), the Guthrie inhibition assay blood test. What action should the nurse implement to ensure the validity of the test? a. Collect the blood prior to the next 4-hour feeding to obtain a fasting specimen. b. Instruct the mother to bring the newborn back in one week to have this test completed. c. Assess the newborn's feeding patterns of formula or breast milk which has "come in." d. Obtain venipuncture specimens to prevent hemolysis when expressed from capillaries. - Ans - C A male client, who has been smoking 1 pack of cigarettes every day for the last 20 years, is scheduled for surgery and will be unable to smoke after surgery. During preoperative teaching, the client asks the nurse what symptoms he may expect after surgery from nicotine withdrawal. Which response is best for the nurse to provide? a. "You should have minimal withdrawal symptoms." b. "Headache and hyperirritability are common " c. "A common withdrawal response is hypertension." d. "Expect to have a loss of appetite and tachycardia." - Ans - B The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take? a. Assess respiratory rate for one minute next. b. Give the medication dosage as scheduled. c. Wait 30 minutes and give half of the dosage of medication. d. Withhold the medication and contact the healthcare provider. - Ans - D An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding? a. Stage 1. b. Stage 2. c. Stage 3. d. Stage 4. - Ans - C

A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, "Why do you have to wear a gown and mask when you are in my room?" How should the nurse respond? a. "There are many forms of bacteria and germs in the hospital." b. "To protect you because you can get an infection very easily." c. "After taking medication for 24 hours a gown and mask won't be needed." d. "Your condition could be spread to staff and other clients in the hospital." - Ans - B During the physical assessment, which finding should the nurse recognize as a normal finding? a. Regular pulsation at the epigastric area when the client is supine. b. Apical pulse noted over an area 4 to 5 centimeters with a duration of 2 seconds. c. Jugular venous pressure palpable with the client in an upright position. d. Point of maximal impulse at the third intercostal space in the right midclavicular line. - Ans - A The nurse is preparing to administer IV fluid to a client with a strict fluid restriction. IV tubing with which feature is most important for the nurse to select? a. Micro drop factor. b. Drop factor of 15 gtt/ml. c. An intact inline filter. d. A Buretrol attachment. - Ans - D The nurse identifies bright-red drainage, about 6 cm in diameter, on the dressing of a client who is one day post abdominal surgery. Which action should the nurse take next? a. Mark the drainage on the dressing and take vital signs. b. Notify the healthcare provider of a potential for hemorrhage. c. Remove the dressing and assess the surgical incision site. d. Reassess dressing in one hour for increased drainage. - Ans - A A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her deceased husband. What nursing problem best describes this problem? a. Confusion related to recent death of loved one. b. Delayed grief reaction related to death of husband. c. Denial related to the loss of a loved one. d. Unresolved anger related to death of husband. - Ans - C Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach? a. Administer after an eight-hour fast. b. Give one hour before or two hours after a meal. c. Provide the dose after the client has missed a meal. d. Take with liquids, but no solid foods. - Ans - B

During the assessment of a 21-year-old female client with bipolar disorder, the client tells the nurse that she has not taken her medication for three years, her mother will not let her return home, and she does not have transportation or a job. Which client goal is most important for this client? a. Taking medication, with community follow-up. b. Obtain housing, with possibility of returning home. c. Become familiar with public transportation. d. Begin vocational rehabilitation. - Ans - A The nurse identifies a client's needs and formulates the nursing problem of, "Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months." Which short-term goal is best for this client? a. Eat 50% of six small meals each day by the end of one week. b. Meals prepared during hospitalization will be fed by the nurse. c. Verbalize understanding of plan and of intention to eat meals. d. Demonstrate progressive weight gain toward the ideal weight. - Ans - A A child with Tetrology of Fallot suffers a hypercyanotic episode. Which immediate action by the nurse can lessen the symptoms of this "TET spell?" a. Remove child's constrictive clothing. b. Place child in knee-chest position. c. Have child stop all current activity. d. Administer a dose of digoxin stat. - Ans - B Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide? a. Initiate the lactation process. b. Prevent neonatal hypoglycemia. c. Stimulate contraction of the uterus. d. Facilitate maternal-infant bonding. - Ans - C The nurse plans to suction a male client who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning this client? a. Suction for only 5 seconds since the client has only one lung and cannot hold his breath for very long. b. Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning. c. Have another person available to hold the client's hands to prevent inadvertent removal of the suction tube. d. Suction deeply and vigorously to ensure that all secretions are removed in order to prevent atelectasis. - Ans - B

A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my husband." What type of thoughts is the client having? a. Obsessive. b. Phobic. c. Delusional. d. Paranoid. - Ans - A The nurse is using the Ages and Stages Questionnaire (ASQ) to screen a 12-month-old infant during a well-child visit. When the parents ask the nurse the reason for this procedure, which response provides the best explanation? a. This tool identifies achievement of development milestones in infants and young children. b. The procedure tests cognitive, physical, and psychological areas of development. c. The examination screens for early speech difficulties so early treatment can begin. d. This test measures intellectual ability and screens for possible learning difficulties later in school. - Ans - A The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement? a. Direct the questions to the spouse whenever possible. b. Repeat each question and tell the client to speak up. c. Ask another nurse to complete the interview. d. Ask the spouse to step out for a few minutes. - Ans - D The nurse is preparing to administer a prescribed dose of acetylcysteine (Mucomyst) 600 mg PO. The 10 ml vial is labeled "Mucomyst 20% solution (20 grams/100 ml)." What volume of medication in milliliters should the nurse administer? (Enter numeric value only.) - Ans - 3 Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers? a. Case manager. b. Nurse-manager. c. Quality manager. d. Discharge manager. - Ans - A The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider? a. Expresses fear about the surgical procedure. b. Recalls drinking a glass of juice after midnight. c. Reports a history of hives after eating shellfish. d. States has a history of post-operative nausea. - Ans - B

A client is being admitted to the medical unit from the emergency department after having a chest tube inserted. What equipment should be brought to this client's room? a. Crash cart. b. Endotracheal tube. c. Rubber-tipped clamps. d. Partial rebreather oxygen mask. - Ans - C A male client with a history of chronic back pain that was managed with opiate analgesics calls the nurse after having back surgery. The client reports that the back pain is finally gone, but after stopping the pain medication, the client has been having severe diarrhea and painful muscle cramps. Which assessment information should the nurse obtain next? a. Did the client receive a prescription for methadone or clonidine? b. Is the client using a fentanyl patch after stopping the opiate analgesic? c. Has the client taken any over-the-counter agents for these symptoms? d. When did the symptoms begin after the last dose of opiate analgesic? - Ans - D The nurse is caring for a client who is one day postoperative after a left total knee arthroplasty (TKA). Which intervention should the nurse include in the plan of care? a. Progressive leg exercises to obtain 90-degree flexion. b. Ambulation with full weight-bearing on first postop day. c. Bed rest for three days with the left knee extended. d. Immobilization of the left knee to prevent dislocation. - Ans - A The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of the phototherapy? a. "I need to change the baby's position every four hours." b. "I should leave the baby under the light all of the time." c. "I will keep the baby's eyes covered when the baby is under the light." d. "I should dress the baby in light clothing when the baby is under the light." - Ans - C A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement? a. Put petroleum jelly on the lips and around the nasogastric tube. b. Allow the client to drink water and record on the I and O record. c. Offer the client ice chips and instruct client to spit out the water. d. Apply a water soluble lubricant to the lips, oral mucosa and nares. - Ans - D A client who is one week postoperative after an aortic valve replacement suddenly develops severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and cool, and no pulses are palpable in the left leg. After notifying the healthcare provider, which action should the nurse take? a. Elevate the legs and medicate for pain.

b. Apply firm pressure to the femoral artery. c. Keep the client in bed in the supine position. d. Encourage the client to exercise the leg. - Ans - C Which statement by the community health nurse is most helpful to an adult who is in a crisis situation? a. "I will be your primary resource person, and will gather the information you need to get through this situation." b. "Based on past coping, I believe you will be able to deal with future problems successfully." c. "I have a plan of action that I think will help you. Would you like to see if it will work for you?" d. "You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it?" - Ans - D A male client who has been taking propranolol (Inderal) for 18 months tells the nurse that the healthcare provider discontinued the medication because his blood pressure has been normal for the past three months. Which instruction should the nurse provide? a. Report any uncomfortable symptoms after stopping the medication. b. Stop the medication and keep an accurate record of blood pressure. c. Ask the healthcare provider about tapering the drug dose over the next week. d. Obtain another antihypertensive prescription to avoid withdrawal symptoms. - Ans - C During a client assessment, the client says, "I can't walk very well." Which action should the nurse implement first? a. Choose the most successful approach. b. Identify the problem. c. Consider alternatives. d. Predict the likelihood of the outcome. - Ans - B Which documentation indicates that the nurse correctly evaluated a pain medication's effectiveness after administration? a. reports decrease in pain. b. complained of pain; PRN pain medication given. c. smiling while visiting with family members. d. was talking on the phone 30 minutes after pain medication was given. - Ans - A A female client tells the nurse that her home pregnancy test is positive and her last menstrual period (LMP) was February 14. The client wants to know the expected date of birth (EDB). How should the nurse respond? a. September 17. b. November 21. c. December 17. d. October 21. - Ans - B

Prenatal diagnostic testing is recommended for a couple expecting their first child who have a family history of congenital disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which concept should the nurse consider when responding to this couple? a. Counselling about advantages and disadvantages of termination should be helpful. b. There is limited value in diagnostic testing if termination of pregnancy is not an option. c. Diagnostic testing may indicate a fetal problem that could be treated prior to delivery. d. Many states legally require prenatal testing as a means of protecting the fetus. - Ans - C The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation? a. A Hispanic client may have inward-turned eyelashes. b. An Asian client may have a horizontal palpebrale fissure. c. An African-American client may have slightly yellow sclerae. d. A Caucasian client may have a slightly protruding eyeball. - Ans - C The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation? a. Thyroid cyst. b. Thyroid cancer. c. Hypothyroidism. d. Hyperthyroidism. - Ans - D A nurse-manager sees a colleague taking drugs from the unit. What action should the nurse-manager take? a. Talk to the colleague about what was seen. b. Report the incident to the immediate supervisor. c. Carefully observe the nurse to verify the behavior. d. Determine if other staff have observed similar behavior. - Ans - B Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit? a. Full rooming-in for the infant and mother. b. Restrict visitors who irritate the client. c. Supervised and guided visits with infant. d. Daily visits with her significant other. - Ans - C Which nursing intervention is an example of a competent performance criterion for an occupational and environmental health nurse? a. Serves as a consultant to businesses and management. b. Implements health programs for construction workers. c. Designs quality improvement methods that measure health outcomes. d. Conducts research studies that enhance health safety. - Ans - B

A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn't want any more contact with the hospital. How should the nurse respond? a. "Because you are leaving against medical advice, you may not have your chart." b. "The information in your chart is confidential and cannot leave this facility legally." c. "This hospital does not need to keep it if you are leaving and not returning here." d. "The chart is the property of the hospital but I will see that a copy is made for you." - Ans - D The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes? a. Educate significant others about providing support for their partner during labor. b. Participants can identify at least three coping strategies to use during labor. c. Teach and practice breathing techniques to help cope with contractions during labor. d. Introduce comfort measures that are effective techniques to use during labor and delivery. - Ans - B The school nurse is reviewing health risks associated with extracurricular activities of grade-school children. Regular participation in which activity places the child at highest risk for developing external otitis? a. Batting practice at a batting cage. b. Soccer practice at an outdoor field. c. Swimming lessons in an indoor pool. d. Roller skating at an indoor rink. - Ans - C The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture? a. Blood urea nitrogen 40 m and creatinine 1.0. b. Cloudy, amber urine with sediment, specific gravity of 1.040. c. Serum potassium of 5.5 mEq and total calcium of 6 mg/dl. d. Hemoglobin of 10 g and hypophosphatemia. - Ans - C In planning the care of a 3-year-old child with diabetes insipidus, it is most important for the nurse to caution the parents to be alert for which condition? a. Increased thirst. b. Soft anterior fontanel. c. Cool, diaphoretic skin. d. Swelling around the eyes and face. - Ans - A When documenting assessment data, which statement should the nurse record in the narrative nursing notes? a. Hair is within normal limits. b. Most all permanent teeth are present.

c. S1 murmur auscultated in supine position. d. Slight tenderness in the left upper quadrant. - Ans - C A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him. What oxygen delivery system is best for this client? a. Rebreather mask. b. Venturi mask. c. Nasal cannula. d. Hand-held nebulizer. - Ans - C What information best supports the nurse's explanation for promoting the use of alternative or complementary therapies? a. Focuses on the pathogenesis of the disease of an individual. b. Replaces the conventional Western modality treatments. c. Recognizes the value of a client's input into their own health care. d. Continues to be used by a limited number of Americans. - Ans - C Preoperatively, a client is to receive 75 mg of meperidine (Demerol) IM. The Demerol solution contains 50 mg/ml. How much solution should the nurse administer? a. 0.5 ml. b. 1 ml. c. 1.5 ml. d. 2 ml. - Ans - C The nurse attempts to notify the healthcare provider about a client who is exhibiting an extrapyramidal reaction to psychotropic medications. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take? a. Ask when the healthcare provider plans to return to the office and the usual office hours. b. Tell the receptionist to have the healthcare provider return the phone call. c. Provide the receptionist with the client's name, age, and type of reaction. d. Ask the receptionist to notify the client's family if the healthcare provider cannot be contacted. - Ans - B A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make? a. How long has the client been taking the medication? b. Does the client use any tobacco products? c. Has the client experienced constipation recently? d. Did the client miss any doses of the medication? - Ans - A Which instruction should the nurse include in the discharge teaching for a client who is taking an antipsychotic medication? a. Increase daily intake of raw fruits and vegetables. b. Follow a low carbohydrate diet.

c. Take a multivitamin daily. d. Report increased urine output to the healthcare provider immediately. - Ans - A Which assessment finding should make the nurse suspect that a 21-year-old male client is taking anabolic steroids? a. Complains of increased facial hair growth. b. Acne increased on face and back. c. Describes working hard to develop muscles. d. Weight gain of 10 pounds in past month. - Ans - C A client with metastatic cancer is preparing to make decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate? a. "It allows you to document your wishes regarding life-sustaining treatment if you can't speak for yourself." b. "It will identify someone that can make decisions for your health care if you are in a coma or vegetative state." c. "It is not legally binding, but helps the healthcare provider know exactly what medical treatments you want." d. "It is a form that all people must sign before admission to the hospital so that individualized treatment plans can be developed." - Ans - B A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma? a. Pindolol (Visken). b. Carteolol (Ocupress). c. Metoprolol tartrate (Lopressor). d. Propranolol hydrochloride (Inderal). - Ans - C The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What response is best for the nurse to provide? a. Provide a more rapid induction of anesthesia. b. Decrease the risk of bradycardia during surgery. c. Induce relaxation before induction of anesthesia. d. Minimize the amount of analgesia needed postoperatively. - Ans - B A nurse whose tuberculosis (TB ) skin test result reveals an 8 mm induration obtains a negative chest radiograph, which indicates latent tuberculosis. The employee-health nurse should implement which intervention for this nurse? a. Repeat the skin test and chest radiograph in three weeks. b. Administer isoniazid (INH) daily for 6 to 9 months. c. Give combination therapy of antitubercular drugs for 6 months. d. Recommend the bacille Calmette-Gu rin (BCG) vaccine. - Ans - B

A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide? a. Low doses of tamoxifen prevent menopausal hot flashes. b. An option used to reduce the risk of breast cancer for all women. c. This anti-estrogen drug inhibits malignancy growth. d. Part of a combination of chemotherapeutic agents used to treat tumors. - Ans - C Prior to a cardiac catheterization, which activity should the nurse have the client practice? a. Flexing hips and knees bilaterally. b. Valsalva's maneuver and coughing. c. Talking while walking on a treadmill. d. Remain motionless for 5 minutes. - Ans - B After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first? a. The client who has a new onset of difficult breathing. b. An anxious client who is 3 days post myocardial infarction. c. The client with type 2 diabetes mellitus who has a call light on. d. A client whose blood transfusion is near completion. - Ans - A When engaging in planned change on the unit, what should the nurse-manager establish first? a. Goals for achieving the change are established. b. Options for accomplishing the change are explored. c. Resources needed for the change are available. d. Staff members are aware of the need for change. - Ans - D When meeting with the client and the family, which nursing intervention demonstrates the nurse's role as collaborator of care? a. Coordinating and educating about multidisciplinary services. b. Providing information on financial assistance programs. c. Referring and consulting with other healthcare specialities. d. Informing about the findings that determine clinical diagnosis. - Ans - A Lasix 20 mg PO is prescribed for a client at 0600. The medication is available in a scored tablet of 40 mg. Before breaking the tablet, what action should the nurse take? a. Apply non-sterile gloves. b. Perform hand hygiene. c. Consult with the pharmacist. d. Chart "half tablet administered." - Ans - B

The scope of professional nursing practice is determined by rules promulgated by which organization? a. State's Board of Nursing. b. State Nursing Associations. c. American Nurses Association (ANA). d. National Labor Relations Board (NLRB). - Ans - A After eye drops are instilled, which instruction should the nurse provide to the client? a. "Tilt your head back." b. "Look to each side." c. "Close your eyelids." d. "Blink quickly 3 times." - Ans - C The nurse manager is assisting a nurse with improving organizational skills and time management. The nurse is developing a plan for the daily assignment of known nursing responsibilities. Which nursing activity is the priority in this pre-planning? a. Medication administration. b. Client personal hygiene. c. Colostomy care instruction. d. Tracheostomy tube suctioning. - Ans - A The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse take? a. Recommend a daily intake of at least four glasses of whole milk. b. Encourage giving two additional snacks each day to the child. c. Question the type and quantity of foods eaten in a typical day. d. Assess for signs of poor nutrition, such as a pale appearance. - Ans - C The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select all that apply.) A.Administer aspirin with tissue plasminogen activator (t-PA). B.Complete the National Institute of Health Stroke Scale (NIHSS). C.Assess the client for signs of bleeding during and after the infusion. D.Start t-PA within 6 hours after the onset of stroke symptoms. E.Initiate multidisciplinary consult for potential rehabilitation. - B,C,E Rationale: Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA because it increases the risk for bleeding (A). The administration of t-PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and within 4.5 hours of symptoms is concurrent for a stroke (D).

When caring for a client in labor, which finding is most important to report to the primary health care provider? A.Maternal heart rate, 90 beats/min. B.Fetal heart rate, 100 beats/min C.Maternal blood pressure, 140/86 mm Hg D.Maternal temperature, 100.0° F - B Rationale: A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the average FHR at term is 140 beats/min and the normal range is 110 to beats/min 160. The others (A, C, and D) are normal findings for a woman in labor. The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nurse take first? A.Draw arterial blood gases. B.Notify the primary health care provider. C.Position in a high Fowler's position with the legs down. D.Obtain a chest X-ray. - C Rationale: Positioning the patient in a high Fowler's position with dangling feet will decrease further venous return to the left ventricle (C). The other actions should be performed after the change in position (A, B, and D). A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity, a shuffling gait, and tremors. Which action by the nurse is most important?A.Administer a dose of benztropine mesylate (Cogentin) PRN. B.Determine if the client has increased photosensitivity. C.Provide comfort measures for sore muscles. D.Assess the client for visual and auditory hallucinations. - A Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are extrapyramidal side effects associated with Thorazine. It is most important for the nurse to administer an anticholinergic such as Cogentin to reverse these effects (A). The others (B, C, D) may be appropriate interventions but are not as urgent as (A). A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse to continue further assessment of the infant? A.Two-month-old who is unable to roll from back to abdomen B.Ten-month-old who cannot sit without support C.Nine-month-old who cries when his mother leaves the room D.Eight-month-old who has not yet begun to speak words - B Rationale: As a developmental milestone, infants should sit unsupported by 8 months (B). The milestone of rolling over is achieved at 5 to 6 months for most infants (A). Stranger anxiety is common from 7 to 9 months (C). Speaking a few words is expected at about 12 months (D).