HES I RN Exit Exam 2024 – Accurate Questions with Verified Answers | Guaranteed Pass, Exams of Nursing

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HESI RN EXIT EXAM 2024 ACCURATE

QUESSTIONS WITH VERIFIED ANSWERS

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Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? a. Ask a more experience nurse to perform that scrub since it is the first time of the day b. Validate the nurse is implementing the OR policy for surgical hand scrub c. Inform the nurse that hand scrubs should be 3 minutes between cases. d. Direct the nurse to continue the surgical hand scrub for a 5-minute duration. Direct the nurse to continue the surgical hand scrub for a 5 minute duration Rationale: The surgical hand scrub should last for 5 to 10 mints, so the nurse should be directed to continue the vigorous scrub using a reliable agent for the total duration of 5 mints. It is not necessary to reassign staff (A). The length of the hand scrub and subsequent scrubs during the day require the same process for the same amount of time, (B and C) Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis? a. Egg whites, toast and coffee. b. Bran muffin, mixed fruits, and orange juice. c. Granola and grapefruit juice d. Bagel with jelly and skim milk. Bagel with jelly and skim milk Rationale: D includes dairy products which contain calcium and does not include any foods that inhibit calcium absorption. The primary dietary implication of osteoporosis is the need for increased calcium and reduction in foods that decrease calcium absorption, such as caffeine and excessive fiber. The charge nurse of critical care unit informed at beginning of shift that less than optimal number registered nurses be working that shift. In planning assignments, which client should receive most care hours by a registered nurse a. A 34 yo admitted today after emergency appendendectomy who has peripheral intravenous catheter, Foley catheter. b. A 48 yo marathon runner w/a central venous catheter experiencing nausea, vomiting due to electrolyte disturbance following a race. c. A 63 yo chain smoker w/ chronic bronchitis receiving O2 nasal cannula and a saline-locked peripheral intravenous catheter. d. An 82 yo client with Alzheimer's disease newly-fractures femur w/Foley catheter and soft wrist restrains applied

An 82 - year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied Rationale: (D) describe the client at the most risk for injury and complications because of the factor listed. (A) has complete the recovery period form anesthesia but requires critical care because of the invasive lines and new abdominal incision. (B) is likely to be in excellent physical condition and has one invasive line needed for rehydration. (C) is essentially stable, despite having a chronic condition. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? a. Cleanse the foot with soap and water and apply an antibiotic ointment b. Provide teaching about the need for a tetanus booster within the next 72 hours. c. have the mother check the child's temperature q4h for the next 24 hours d. transfer the child to the emergency department to receive a gamma globulin injection Cleanse the foot with soap and water and apply an antibiotic ointment Rationale: The nurse should cleanse the wound first and implement B next. The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement." What instruction should the nurse provide? a. Antibiotics take two weeks to become effective against infections such as athlete's foot. b. Continue using the ointment for a full week, even after the symptoms disappear. c. Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration. d. Stop using the ointment and encourage complete drying of the feet and wearing clean socks. Stop using the ointment and encourage complete drying of the feet and wearing clean socks. Rationale: Athlete's foot (tinea pedi) is a fungal infection that afflicts the feet and causes scaliness and cracking of the skin between the toes and on the soles of the feet. The feet should be ventilated, dried well after bathing, and clean socks should be placed on the feet after bathing. Antifungal ointments may be prescribed, but antibiotic ointments are not useful. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences

a. Palpitations and shortness of breath b. Bradycardia and constipation c. Lethargy and lack of appetite d. Muscle cramping and dry, flushed skin Palpitations and shortness of breath Rationale: An overdose of thyroid preparation generally manifests symptoms of an agitated state such as tremors, palpitations, shortness of breath, tachycardia, increased appetite, agitation, sweating and diarrhea. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? a. Determine the client's level of orientation and cognition b. Assess distal pulses and signs of peripheral edema c. Obtain a list of medications taken for cardiac history. d. Ask the client about exposure to environmental heat. Obtain a list of medications taken for cardiac history Rationale: The client is presenting with signs of digitalis toxicity. A list of medication, which is likely to include digoxin (Lanoxin) for heart failure, can direct further assessment in validating digitalis toxicity with serum labels greater than 2 mg/ml that is contributing to client's presenting clinical picture. The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) 75 75 Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) a. Bleeding that results from a decreased production of the body's clotting factors b. Fluid shifts from intravascular to interstitial area due to decreased serum protein c. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen d. Increased circulating aldosterone levels that increase sodium and water retention e. Decreased absorption of fatty acids in the duodenum leading to abdominal distention. b. Fluid shifts from intravascular to interstitial area due to decreased serum protein c. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen

d. Increased circulating aldosterone levels that increase sodium and water retention Rationale: When liver fail production of albumin is reduced. Since albumin is the primary serum protein creating intravascular osmotic pressure, decreased serum protein allows a fluids shift into the interstitial space. Pressure increases in the portal circulation © when venous return from the upper GI tract cannot flow freely into sclerosed liver, which cause a pressure gradient to further Increase fluid shifts into the abdomen. A failing liver ineffectively inactivates steroidal hormones, such as aldosterone resulting in sodium and water retention. The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) a. S1 S b. S1 S2 S c. Murmur d. Pericardial friction rub. Murmur Rationale: A murmur is auscultated as a swishing sound that is associated with the blood turbulence created by the heart or valvular defect. B is associate with Heart Failure. The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth. 0.

rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? a. Auscultate the client's bowel sounds b. Observe for edema around the ankles c. Measure the client's capillary glucose level d. Count the apical and radial pulses simultaneously Auscultate the client's bowel sounds Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes constipation, so it is most important to Auscultate the client's bowel sounds A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants

"no heroic measures" taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? Ask the client to discuss "do not resuscitate" with her healthcare provider Ask the client to discuss "do not resuscitate" with her healthcare provider A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? a. Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour b. Continue the full strength feeding after decreasing the rate of infusion to 25 ml/hr. c. Maintain the present feeding until diarrhea subsides and the begin the next new prescription. d. Withhold any further feeding until clarifying the prescription with healthcare provides. Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour Rationale: Diluting the formula can help alleviate the diarrhea. Diarrhea can occur as a complication of enteral tube feeding and can be due to a variety of causes including hyperosmolar formula. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? a. "Is there a history of female baldness in your family?" b. "Are you under any unusual stress at home or work?" c. "Do you work with hazardous chemicals?" d. "Have you noticed any changes in your fingernails?" Have you noticed any changes in your fingernails? Rationale: The pattern of reported manifestations is suggestive of hypothyroidism After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? a. Bruises on arms and legs b. Round and tight abdomen c. Pitting edema in lower legs d. Capillary refill of 8 seconds Capillary refill of 8 seconds Rationale: The client is bleeding and hypovolemia is likely. Capillary refill is greater than 3 to 5 seconds indicates poor perfusion and requires immediate attention

After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse's signature on the client's surgical consent form? (Select all that apply) a. The client voluntarily grants permission for the procedure to be done b. The surgeon has explained to the client why the surgery is necessary. c. The client is competent to sign the consent without impairment of judgment d. The client understands the risks and benefits associated with the procedure e. After considering alternatives to surgery, the client elects to have the procedure. a. The client voluntarily grants permission for the procedure to be done c. The client is competent to sign the consent without impairment of judgment d. The client understands the risks and benefits associated with the procedure Rationale: Inform consent is required for any invasive procedure. The nurse's signature as a witness to the client's signature on surgical consent indicates that the client voluntary gives consent for the scheduled procedure. C is competent to give consent, and D and understand the risk and benefits of the procedure. Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? a. Ask the client to explain why he constantly request the nurse b. Encourage the client to verbalize his feelings about the nurse c. Reassure the client that his request will be met whenever possible. d. Advise the client that assignments are not based on client requests Advise the client that assignments are not based on clients requests Rationale: Those with antisocial personality disorders are manipulative in order to meet their own needs. The charge nurse must set limits on this behavior. The client's superficial charm and emotional maturity prevent effective therapeutic communication and (A and B) will be used to the client's advantage. C encourage further manipulative behavior. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? a. Call the radiology department b. Reinsert the implant into the vagina c. Apply double gloves to retrieve the implant for disposal. d. Place the implant in a lead container using long-handled forceps Place the implant in a lead container using long-handled forceps

Rationale: Solid or sealed radiation sources, such as Cesium which is removed after treatment, are inserted into an applicator or cervical implant to emit continuous, low energy radiation for adjacent tumor tissues. If the radiation source or the applicator become dislodged long-handled forceps should be used to retrieve the radiation implant to prevent injury due to direct handling. The applicator is then placed in the lead container. The client with which type of wound is most likely to need immediate intervention by the nurse? a. Laceration b. Abrasion c. Contusion d. Ulceration Laceration Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care? a. Record urine output every hour b. Monitor blood pressure frequently c. Evaluate neurological status d. Maintain seizure precautions Monitor blood pressure frequently Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? a. To reduce abdominal pressure on the diaphragm b. to promote retraction of the intercostal accessory muscle of respiration c. to promote bronchodilation and effective airway clearance d. to decrease pressure on the medullary center which stimulates breathing To reduce abdominal pressure on the diaphragm Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to

locate the gallbladder by palpation? a. The client is too obese b. Palpating in the wrong abdominal quadrant c. The gallbladder is normal d. Deeper palpation technique is needed The gallbladder is normal Rationale: a normal healthy gallbladder is not palpable A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? a. Describe the transmission of drugs to the infant through breast milk b. Encourage her to use stress relieving alternatives, such as deep breathing exercises c. Inform her that some antianxiety medications are safe to take while breastfeeding d. Explain that anxiety is a normal response for the mother of a 3-week-old. Inform her that some antianxiety medications are safe to take while breastfeeding Rationale: There are several antianxiety medications that are not contraindicated for breastfeeding mothers. The woman is apparently aware that drugs can be transmitted through breast milk, so A is not helpful. C might be helpful, but the client's history suggest that nonpharmacological methods of anxiety management do not produce the best outcome. (D) the mother's history places her at risk for severe anxiety. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? a. obtain a serum potassium level b. administer the client's usual dose of insulin c. assess pupillary response to light d. Start an intravenous (IV) infusion of normal saline Start an intravenous (IV) infusion of normal saline Rationale: the nurse should first start an intravenous infusion of normal saline to replace the fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which also contributes to diuresis and fluid electrolyte imbalance. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the

nurse's decision to hold the client's scheduled antihypertensive medication? a. Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure b. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness c. The additive effect of multiple medications has caused the blood pressure to drop too low. d. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension. The additive effect of multiple medications has caused the blood pressure to drop too low Rationale: When medication with a similar action are administered, an additive effect occurs that is the sum of the effects of each of the medication. In this case, several medications that all lower the blood pressure, when administer together, resulted in hypotension. Which client is at the greatest risk for developing delirium? a. An adult client who cannot sleep due to constant pain. b. an older client who attempted 1 month ago c. a young adult who takes antipsychotic medications twice a day d. a middle-aged woman who uses a tank for supplemental oxygen An adult client who cannot sleep due to constant pain. Rationale: Client who are in constant pain ad have difficulty sleeping or resting are at high risk for delirium. Supplemental oxygen may cause confusion. B is taking medication so is not at high risk of delirium. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? a. Reduce risks factors for infection b. Administer high flow oxygen during sleep c. Limit fluid intake to reduce secretions d. Use diaphragmatic breathing to achieve better exhalation Reduce risks factors for infection Rationale: Interventions aimed at reducing the risk factors of infections should be included in the plan of care COPD client are at particular risk for respiratory infection. Prevention and early detection of infections are necessary. Which location should the nurse choose as the best for beginning a screening program for hypothyroidism?

a. A business and professional women's group. b. An African-American senior citizens center c. A daycare center in a Hispanic neighborhood d. An after-school center for Native-American teens A business and professional women's group Rationale: The population at highest risk is A so this is the group that would benefit the most for a screening program of hypothyroidism and occurs between 35 and 60 years of age and is most common in females. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling "very tired". Which nursing intervention is most important for the nurse to implement? a. Measure vital signs b. Auscultate breath sounds c. Palpate the abdomen d. Observe the skin for bruising Measure vital signs Rationale: Abrupt withdrawal of an exogenous corticosteroids can precipitate adrenal insufficiency and hypoglycemia, hypokalemia, and circulatory collapse can occur. Is most important for the nurse to assess vital sign to impending shock. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider? a. capillary glucose b. urine specific gravity c. Serum calcium d. white blood cell count Serum calcium Rationale: Numbness and tingling of the fingers and around the mouth, along with muscle cramps are signs of hypocalcemia What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? a. working together can decrease the risk for back injury b. The technique is intended to maintain straight spinal alignment. c. Using two or three people increases client safety. d. turning instead of pulling reduces the likelihood of skin damage The technique is intended to maintain straight spinal alignment. Rationale: The main rationale for use of the long-rolling technique is to maintain the client's spine straight alignment.

A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client? a. Plain yogurt with sweetened with raw honey b. Peanuts in the shell, roasted or un-roasted. c. Aged farmer's cheese with celery sticks d. Baked apples topped with dried raisins Baked apples topped with dried raisins Rationale: A patient with chemotherapy-induced severe neutropenia is at high risk for infection. A low bacteria diet is required D is a healthy snack for a client receiving chemotherapy. A, B and C have a high bacterial count and should be avoided. Which action should the school nurse take first when conducting a screening for scoliosis? a. Compare dorsal measurement of trunk b. Extend arms over head for visualization c. Inspect for symmetrical shoulder height. d. Observe weight-bearing on each leg. Inspect for symmetrical shoulder height. Rationale: Children between 9 and 15 years old should be screening for scoliosis, which is exhibited.... Vertebral column. Screening for scoliosis should begin with inspection of shoulder height An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement? a- Instruct the UAP to count the client apical pulse rate for sixty seconds b- Determine if the UAP also measured the client's capillary refill time. c- Assign a practical nurse (LPN) to determine if an apical radial deficit is present. d- Notify the health care provider of the abnormal pulse rate and pulse volume. Assign a practical nurse (LPN) to determine if an apical radial deficit is present After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan? a. Describe the signs and symptoms of hypoglycemia. b. Encourage a low-carbohydrate and high-protein diet c. Reinforce the need to continue outpatient treatment d. Suggest wearing a medical alert bracelet at all time. Encourage a low-carbohydrate and high-protein diet Rationale: A client with anorexia nervosa with long term starvation or who self-restrict

intake can sign.... Reserves. Providing the client with dietary selections such as low- carbohydrate, high protein.... Hypoglycemic episodes, which can become life-threating. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform? Observe the antecubital fossa for inflammation. Observe the antecubital fossa for inflammation. The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply

**- White blood cell (WBC) count

• Sputum culture and sensitivity**
• White blood cell (WBC) count
• Sputum culture and sensitivity A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement? Negative pressure environment Negative pressure environment A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child Sitting up and leaning forward Sitting up and leaning forward A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs Rented movies and borrowed books to use while passing time at home Rented movies and borrowed books to use while passing time at home Which instruction should the nurse provide a pregnant client who is complaining of heartburn? a. Limit fluids between meals to avoid over distension of the stomach b. Take an antacid at bedtime and whenever symptoms worsen c. Maintain a sitting position for two hours after eating. d. Eat small meal throughout the day to avoid a full stomach. Eat small meal throughout the day to avoid a full stomach. Rationale: Eating small frequent meals throughout the day decreases stomach fullness and helps decrease heartburn. Fluids should not be consumed with foods because they further distend the stomach, but fluids not be limited between meals (A) because this puts the client at risk for dehydration. (B) is not recommended during pregnancy unless prescribed by the health provider because they place the client at risk for electrolyte

imbalance (sodium), constipation (aluminum, or diarrhea (magnesium) (C) is less effective than (D) preventing heartburn. A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? a. Hypokalemia b. Ketonuria. c. Peripheral edema d. Elevated blood pressure Hypokalemia Rational: pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement? Digitally check the client for a fecal impaction Digitally check the client for a fecal impaction After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse? Bilateral Wheezing. Bilateral Wheezing. The nurse should teach the parents of a 6 year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response? Inflammation of the mucous membrane & bronchospasm Inflammation of the mucous membrane & bronchospasm A 10 year old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond? a. "Your mother & father will be here soon. Talk to them about that." b. "Why do you want to know about what will happen to your body when you die?" c. "The heart will stop beating & you will stop breathing." d. "Are you concerned about where your spirit will go?" "The heart will stop beating & you will stop breathing." The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply:

a. Restlessness b. Clenched Fist c. Increased pulse rate d. Increased respiratory rate. e. Increased temperature f. Peripheral pallor of the skin a. Restlessness b. Clenched Fist c. Increased pulse rate d. Increased respiratory rate. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication a. Ask the client about soft foods preferences b. Auscultate the client's breath sounds c. Obtain and record the client's vital signs d. Determine which side of the body is weak. Determine which side of the body is weak. The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse? a. Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing. b. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-pratt drain. c. Collapsed lung after a fall 8h ago with 100 ml blood in the chest tube collection container d. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. Rationale: the client with an abdominal- perineal resection is at risk for peritonitis and needs to be immediately assessed for other signs and symptoms for sepsis. The nurse is caring for a client who had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours? a. Insert an indwelling urinary catheter b. Monitor for the appearance of an incisional hernia c. Instruct the client to eat small frequent meals d. Measure hourly urinary output.

Measure hourly urinary output. Rationale: a serious early complications of gastric bypass surgery is an anastomoses leak, often resulting in death. When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement? a. Administer anti-anxiety medication prior to providing discharge instructions b. Schedule an appointment for an out-patient psychosocial assessment. c. Obtain a blood cortisol level after last dose of synthetic ACTH d. Encourage the healthcare provider to delay the client's discharge. When preparing to administer a prescribed medication to a homeless client at a community psychiatric clinic. The client tells the nurse that the usual dosage taken is different from the dose the nurse is giving. Which action should the nurse take? A) Inform the client that he may refuse the medication and document whether or not the client takes it. B) Withhold the medication until the dosage can be confirmed. C) Explain to the client that the dosage has been changed. D) Tell the client to take the medication then verify the dosage at the next healthcare team meeting. - Ans - B) Withhold the medication until the dosage can be confirmed. The charge nurse is making assignments for one practical nurse and three registered nurses who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN? A) Subdural hematoma whose blood pressure changed from 150/80 to 170/60. B) Viral meningitis whose temperature change from 101 S to 102F. C) Diabetic keto acidosis who is Glasgow coma scale score changed from 10 to 7. D) Myxedema, whose blood pressure change from 80/50 to 70/40. - Ans - B) Viral meningitis whose temperature change from 101 S to 102F. The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care? A) Maintain strict intake and output. B) Keep head of bed raised 45°. C) Excess warmth of extremities. D) Monitor blood glucose level. - Ans - A) Maintain strict intake and output. And adolescent client is admitted to the hospital because of writing a suicide note to a teacher at school. On the second day of hospitalization, the nurse asked the client to

meet with the treatment team. After the team meeting, the client leaves in tears and goes to their room. Which nursing intervention is best? A) Let the client rest quietly in their room for a while. B) Explore the clients goals and desire for treatment. C) Ask the treatment team about the clients behavior. D) Go to the clients room and ask what happened. - Ans - D) Go to the clients room and ask what happened. The healthcare provider prescribes dalteparin 200 units per kilogram subcutaneous once a day for a client who weighs 154 pounds. The medication is available and 25, units per milliliter vial. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest 10th.) - Ans - 0. NGN: The client is a 49-year-old male who reports flu like symptoms including fever and chest congestion for four days. He came to the emergency department last night when he was having more difficulty breathing he has a history of 1/2 pack a day cigarette smoking for 20 years. He has no significant medical or surgical history. Which two orders should the nurse complete first? A) Sputum culture. B) Start oxygen 3 L per minute via nasal cannula. C) Place the client on a cardio respiratory monitor. D) Chest x-ray. E) Acetominophen 350 mg PO every six hours for temperature control. F) Run 0.9% sodium chloride IV infusion at 150 mL per hour. G) Start peripheral IV. H) NPO. - Ans - B) Start oxygen 3 L per minute via nasal cannula. C) Place the client on a cardio respiratory monitor. NGN: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start a peripheral IV infusion, start oxygen 3 L per minute via nasal cannula, begin 0.9% sodium chloride IV infusion at 150 mL per hour, acetaminophen 350 mg PO every six hours for temperature. To start the client on oxygen as ordered which items should the nurse collects from the supply room? SATA A) humidifier bottle. B)Suction canister. C)Sterile water. D) Nasal cannula. E) Flow meter. F) Lambs wool. G) Tape. - Ans - D) Nasal cannula. E) Flow meter.

NGN: states, I am feeling extremely anxious right now. The client has decreased breath sounds in the left lower low. His mucus membranes are dry. He has a productive cough with thick, yellow secretions. His capillary refill is four seconds. Vital signs, temperature 100.2. Heart rate 101 bpm, respiratory rate 28 breaths per minute, blood pressure 145/89, oxygen saturation 90% on room air. (for each body system click to specify the assessment findings that indicates hypoxia) Cardiovascular: heart rate 100 bpm, capillary refill for seconds, blood pressure 145/89. Neurological: anxious, awake and alert, restless. Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm, productive cough. - Ans - Cardiovascular: capillary refill for seconds, blood pressure 145/89. Neurological: anxious, restless. Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm. NGN: The client is a 49-year-old male who reports flu like symptoms including fever and chest congestion for four days. He came to the emergency department last night when he was having more difficulty breathing he has a history of 1/2 pack a day cigarette smoking for 20 years. He has no significant medical or surgical history. The nurse should place the client in a _______________ position to promote _____________. - Ans - Semi-Fowler , lung expansion. NGN: Orders: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start a PIV, start oxygen 3L via nasal cannula, normal saline 150 ML per hour, acetaminophen 350mg PO every six hours for temp greater than 101F, chest x-ray. 0500: Oxygen 8Lvia simple facemask, titrate to keep oxygen saturation greater than 94%. (mark whether the statements by the new grad nurse indicate understanding or no understanding of the use of facemask in the care of this client)

• I should clean the facemask once per shift.
• The client should take a 1 to 2 minute break from the facemask each hour.
• I should put gauze under the elastic straps over the ears.
• I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation greater than 94%.
• The mask should cover only the mouth and leave the nose open for expiration.
• I should place the mask first over the nose and then cover the mouth. - Ans - - I should clean the facemask once per shift. (UNDERSTANDING)
• The client should take a 1 to 2 minute break from the facemask each hour. (NOT UNDERSTANDING)
• I should put gauze under the elastic straps over the ears. (NOT UNDERSTANDING ????)
• I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation greater than 94%. (UNDERSTANDING)

• The mask should cover only the mouth and leave the nose open for expiration. (NOT UNDERSTANDING)
• I should place the mask first over the nose and then cover the mouth. (UNDERSTANDING) NGN: Nurses Notes: 0400, the client is awake and alert but restless. He states I am feeling extremely anxious right now. The client has decreased breath sounds in the left lower lobe. His mucus membranes are dry. He has a productive cough with thick, yellow secretions. His capillary refill is four seconds. Heart rate 101 BPM, oxygen saturation 90%. Blood pressure 145/89, temperature 100.2 F, respiratory rate 28 BPM. 0500: Placedthe client in semi-Fowlers position. No improvement in oxygen saturation on 3L nasal cannula... (Which are the three most important goals?) A) The client will remain free of skin breakdown. B) The client will have quit smoking. C) The client will be afebrile for 24 hours. D) The client will maintain oxygen saturation of 96% without supplemental oxygen. E) The client will report pain less than 3/10. - Ans - B) The client will have quit smoking. C) The client will be afebrile for 24 hours. E) The client will report pain less than 3/10. The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high-protein diet is encouraged to promote wound healing. Which lunch toys by the client indicates that the teaching was effective? A) A peanut butter sandwich with soda and cookies. B) Vegetable soup, crackers, and milk. C) A tuna fish sandwich with chips and ice cream. D) A salad with three kinds of lettuce and fruit. - Ans - C) A tuna fish sandwich with chips and ice cream. A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected MRSA. Which nursing intervention should the nurse include in the plan of care? SATA. A) Institute contact precautions for staff and visitors. B) Use standard precautions and wear a mask. C) Send wound drainage for culture and sensitivity. D) Monitor the clients white blood cell count. E) Explain the purpose of a low bacteria diet. - Ans - A) Institute contact precautions for staff and visitors. C) Send wound drainage for culture and sensitivity. D) Monitor the clients white blood cell count.

An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? A) Weight loss of 10 pounds in the past month. B) Six hours of sleep in the past three days. C) Blood alcohol level of 0.09%. D) Serum lithium level of 1.6. - Ans - D) Serum lithium level of 1.6. When conducting diet teaching for a client who is on a post operative full liquid diet, which foods should the nurse encouraged the client to eat? SATA. A) Clear beef broth. B) Vanilla frozen yogurt. C) Vegetable juice. D) Creamy peanut butter. E) Canned fruit cocktail. - Ans - A) Clear beef broth. B) Vanilla frozen yogurt. C) Vegetable juice. An infant born with esophageal atresia and tracheoesophageal fistula receives a prescription for internal feedings after corrective surgery. To promote normal growth and development of the infant, which action should the nurse include in the plan of care? - Ans - Offer a pacifier for non-Nutritive sucking The nurse is preparing a four year-old client with a serum bilirubin level of 19 for discharge from the hospital. When teaching the parents about home photo therapy, which instruction should the nurse include in the discharge teaching plan? A) Cover with a receiving blanket. B) Perform diaper changes under the light. C) Feed the infant every four hours. D) Reposition the infant every two hours. - Ans - D) Reposition the infant every two hours. The nurse initiate the procedure to remove a clients peripherally inserted central catheter when a code blue is called for another client in the unit who collapse in the hallway while ambulating with the unlicensed assistive personnel. Which action should the nurse take? A) Close the room door. B) Finish the procedure. C) Respond to the code. D) Call for an assistant. - Ans - B) Finish the procedure.

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium? A) Maintain a quiet, non-stimulating environment. B) Confront the clients denial of substance abuse. C) Force oral fluids and provide frequent small meals. D) Encourage attendance and group participation. - Ans - A) Maintain a quiet, non- stimulating environment. A client arrives at the emergency department describing chest pain that began three hours earlier which has not subsided. To assess the quality of the clients chest pain. Which approach for the nurse use? A) Provide a numeric pain scale. B) Ask the client to describe the pain. C) Identify effective pain relief measures. D) Observe body language and movement. - Ans - B) Ask the client to describe the pain. An adolescent who was diagnosed with type one diabetes Molite us at the age of nine, is admitted to the hospital in diabetic keto acidosis. Which occurrence is the most likely cause of the keto acidosis? A) Ate an extra peanut butter sandwich before gym class. B) Incorrectly administered too much insulin. C) Had a cold and ear infection for the past two days. D) Skipped eating lunch while at school. - Ans - C) Had a cold and ear infection for the past two days. When is it most important for the nurse to assess a pregnant client's deep tendon reflexes? A) Within the first trimester of pregnancy. B) When the client has ankle edema. C) During admission to labor and delivery. D) If the client has an elevated blood pressure. - Ans - D) If the client has an elevated blood pressure. NGN: The client has returned to work at in accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informed that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all". In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.

(highlight areas in the above paragraph that the nurse should...) - Ans - - she only gets 2 to 3 hours of sleep due to nightmares about the crash.

• She feels that she is "jumpy" after the accident, especially when she is in the car.
• "I feel so sad that I can't seem to feel anything at all" The client is a 26 year old female who was in a car accident six months ago that killed her mother, husband, and two year old son. She and her father were the only survivors of the crash. She is seeking care for depression. The client is exhibiting symptoms of ________________________ related to ______________ and ___________________. - Ans - Post traumatic stress disorder , experiencing a life-threatening event , losing a loved one. NGN: Orders, diagnosis, depression and posttraumatic stress disorder. Diphenhydramine 12.5 mg PO every night at sleep. BuspironeHydrochloride 7.5 mg PO twice a day. (how can the nurse build a therapeutic relationship with the client? Select all that apply) A) The nurse can show no emotion when talking to the client. B) The nurse can be open honest and sincere. C) The nurse can talk as much as needed to get the client talking. D) The nurse can focus energy on the client. E) The nurse can communicate acceptance of the client as she is F) The nurse can establish a meaningful connection. - Ans - B) the nurse can be open, honest and sincere. E) The nurse can communicate acceptance of the client as she is F) The nurse can establish a meaningful connection. NGN: The client has returned to work at in accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informed that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all". In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use. The client states, "I don't want to kill myself, but sometimes I wish I had died in the crash." The statement by the client presents _______________ and should be followed up with _____________. - Ans - Suicidal ideation, assessment of respecters for suicide. The client is a 26 year old female who was in a car accident six months ago that killed her mother, husband, and two year old son. She and her father were the only survivors of the crash. She is seeking care for depression.

(what would be some affective strategies that the nurse could use to decrease the clients risk of suicide in the future? SATA.) A) Have the client remove any sharp objects from the home. B) Have the client sign a no suicide contract. C) Help the client unless the help of friends and family. D) Make the client feel too guilty to commit suicide. E) Place the client in a locked unit. F) Refer the client for cognitive behavioral therapy. - Ans - B) Have the client sign a no suicide contract. C) Help the client unless the help of friends and family. F) Refer the client for cognitive behavioral therapy. The client is a 26 year old female who was in a car accident six months ago that killed her mother, husband, and two year old son. She and her father were the only survivors of the crash. She is seeking care for depression. (which findings are effective or ineffective)

• The client states she feels less jumpy and more relaxed.
• The client states she feels numb when thinking about the crash.
• The client talks to her father and her best friend when she starts to feel sad.
• The client reports sleeping 6 to 7 hours per night.
• The client states that she avoids driving altogether and takes the bus. - Ans - - The client states she feels less jumpy and more relaxed. (EFFECTIVE)
• The client states she feels numb when thinking about the crash. (INEFFECTIVE)
• The client talks to her father and her best friend when she starts to feel sad. (EFFECTIVE)
• The client reports sleeping 6 to 7 hours per night. (EFFECTIVE)
• The client states that she avoids driving altogether and takes the bus. (INEFFECTIVE) The healthcare provider prescribes acarbose, an alpha-glucosidase inhibitor, for a client with type two diabetes. Which information provides the best indicator of the drugs effectiveness? A) Body mass index between 20 and 24. B) Blood pressure readings less than 120/80. C) Self-reported glucose levels 120 to 150. D) Hemoglobin A1c readings less than 7%. - Ans - D) Hemoglobin A1c readings less than 7%. After receiving report on an inpatient acute care unit which client should the nurse assess first? A) The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds.

B) The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid. C) The client with an obstruction of the large intestine who is experiencing abdominal distention. D) The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. - Ans - D) The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity. Client presents at the emergency department reporting a raspy voice, cold intolerance, and fatigue. Laboratory tests indicate an elevated thyroid stimulating hormone and a low T3 and T4 levels. After the client is admitted to the telemetary unit, which intervention is most appropriate for the nurse to implement? A) administer prescribed dose of level thyroxine. B) Note clients most recent hemoglobin level. C) Offer additional blankets and a warm drink. D) Assess for the presence of nonpitting edema. - Ans - A) administer prescribed dose of level thyroxine. While caring for a client post operative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take? A) Determine if the drainage has an unpleasant odor. B) Cleanse the wound with a sterile saline solution. C) Monitor the clients white blood cell count. D) Request a culture and sensitivity of the wound. - Ans - D) Request a culture and sensitivity of the wound. The school nurse is screening students for scoliosis and notes that one student has lordosis. Which finding should the nurse document in the student screening record? A) Lateral curvature that creates a symmetry of the shoulders. B) Posterior curvature that is convex in the thoracic area. C) Excessive concave curvature of the lumbar spine. D) Rounded spine from head to hips without concave curbs. - Ans - C) Excessive concave curvature of the lumbar spine. The nurse is assigned to care for for surgical clients. After receiving report, which client should the nurse see first? A) An older client who is receiving packed red blood cells on the third day post operative for colon resection. B) An older client with continuous bladder irrigation who is two days post operative for bladder surgery.

C) An adult who is in bucks traction, and scheduled for hip arthroplasty within the just 12 hours. D) An adult one day post operative laparoscopic cholecystectomy requesting pain medication. - Ans - A) An older client who is receiving packed red blood cells on the third day post operative for colon resection. The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situation and perceived stress. In addition to information about prescribe medication and administration, which instruction should the nurse include in the teaching? A) Think about reasons the episodes occur. B) Center attention on positive upbeat music. C) Practice using muscle relaxation techniques. D) Find outlets for more social interaction. - Ans - C) Practice using muscle relaxation techniques. The nurse is preparing a client who had a below the knee amputation for discharge to home. Which recommendations should the nurse provide this client? SATA. A) Use a residual limb shrinker. B) Inspect skin for redness. C) Apply alcohol to the residual limb after bathing. D) Wash the residual limb with soap and water. E) Avoid range of motion exercises. - Ans - A) Use a residual limb shrinker. B) Inspect skin for redness. D) Wash the residual limb with soap and water. The nurse is assessing the feet of a client with type one diabetes mellitis. Which finding requires immediate intervention by the nurse? A) Hard, painless nodule over metatarsophalangeal joint of first toe. B) Painful corns and calluses over hammer toes on both feet. C) Erythema and edema at the base of the left great toe. D) Decreased response to pain discrimination on dorsal surface of foot. - Ans - D) Decreased response to pain discrimination on dorsal surface of foot. The school nurse is called to the soccer field because a child has epistaxis. In which position should the nurse place the child? A) Side-lying with the head slightly elevated. B) Sitting up and leaning forward. C) Standing with the head leaning backwards. D) Supine with the legs raised. - Ans - B) Sitting up and leaning forward.

The nurse is auscultating a clients lung sounds. Which description should the nurse use to document this sound? Please listen to the audio file to select the option that applies. A) High pitch squeeze. B) Rhonchi. C) High-pitched or fine crackles. D) Stridor. - Ans - C) High-pitched or fine crackles. NGN: Flow Sheet, vital signs, heart rate 104 bpm, respiratory rate 31 bpm. The client is experiencing __________________ and ____________________. - Ans - Tachypnea , tachycardia NGN: Orders, 1300 admit to the surgical unit, vital signs every four hours, advanced diet as tolerated, administer lactated ringers IV at 85 mL per hour, ibuprofen 800 mg PO every eight hours PRN for pain. (the nurse would anticipate which of the following could be affecting the clients current condition? SATA. A) stress. B) Medication. C) Anemia. D) Fever. E) Hypothermia. F) Hypertension. G) Pain. - Ans - A) stress. B) Medication. G) Pain. NGN: the client is a 34-year-old female who had a surgical procedure to remove a benign abdominal tumor. (Select which is understanding or not understanding)

• The tubing should be tucked under the chin and secured with the sliding adjustment piece.
• Humidification of oxygen is not needed for administration under 4 L per minute.
• The nasal cannula can deliver up to 10 L per minute of oxygen.
• A nasal cannula delivers 100% oxygen to the client. - Ans - - The tubing should be tucked under the chin and secured with the sliding adjustment piece. (UNDERSTANDING)
• Humidification of oxygen is not needed for administration under 4 L per minute. (UNDERSTANDING)
• The nasal cannula can deliver up to 10 L per minute of oxygen. (NOT UNDERSTANDING)
• A nasal cannula delivers 100% oxygen to the client. (NOT UNDERSTANDING)