HESI EXIT NGN, HESI RN Exit Exam (2025) questions and answers, Exams of Medicine

HESI EXIT NGN, HESI RN Exit Exam (2025) questions and answers

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2024/2025

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HESI EXIT NGN, HESI RN Exit Exam (2025)
A pt presses the call bell and requests pain medication for a severe headache. To
assess the quality of the pt. Pain, which approach should the nurse use? - (correct
Answer) - Ask the patient to describe the pain
The nurse is wearing personal protective equipment while caring for a pt. When
exiting the room, which PPE should be removed first? - (correct Answer) - Gloves
An older pt is brought to the ED with a sudden onset of confusion that occurred after
experiencing a fall at home. The daughter, who has power of attorney, has brought
the client's prescriptions. Which information should the nurse provide first when
reporting to the healthcare provider using SBAR communication? - (correct Answer)
- Increasing confusion of the pt.
A pt tells the nurse about working out with a personal trainer and swimming three
times a week in an effort to lose weight and sleep better. The pt states that it still is
taking hours to fall asleep at night. Which action should the nurse implement? -
(correct Answer) - Ask the pt for a description of the exercise schedule that is being
followed
2 days prior to discharge from the rehab facility, the nurse is teaching a pt who is
recovering from Guillain-Barre syndrome about home. Which actions should the
nurse include when providing discharge teaching to the pt and spouse? SATA -
(correct Answer) - -review safe transfer strategies
-develop a nutritional plan
-help identify community support
The nurse implements a tertiary prevention program for type 2 diabetes in a rural
health clinic. Which outcome indicates that the program was effective? - (correct
Answer) - pt who develop disease complications promptly received rehabilitation
The nurse has received funding to design a health promotion project for African
American women who are at risk for developing breast cancer. Which resource is
most important in designing this program? - (correct Answer) - participation of
community leaders in planning the program
A pt with multiple injuries is being treated in the burn trauma unit just hours after
the injuries occurred. The healthcare provider instructs the nurse to avoid auto
contamination when performing dressing changes. Which intervention is most
important for the nurse to implement? - (correct Answer) - use gown, mask, and
gloves with dressing changes
A pt is recovering in the critical care unit following a cardiac cath. IV nitro and
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HESI EXIT NGN, HESI RN Exit Exam (2025) A pt presses the call bell and requests pain medication for a severe headache. To assess the quality of the pt. Pain, which approach should the nurse use? - (correct Answer) - Ask the patient to describe the pain The nurse is wearing personal protective equipment while caring for a pt. When exiting the room, which PPE should be removed first? - (correct Answer) - Gloves An older pt is brought to the ED with a sudden onset of confusion that occurred after experiencing a fall at home. The daughter, who has power of attorney, has brought the client's prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR communication? - (correct Answer)

  • Increasing confusion of the pt. A pt tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose weight and sleep better. The pt states that it still is taking hours to fall asleep at night. Which action should the nurse implement? - (correct Answer) - Ask the pt for a description of the exercise schedule that is being followed 2 days prior to discharge from the rehab facility, the nurse is teaching a pt who is recovering from Guillain-Barre syndrome about home. Which actions should the nurse include when providing discharge teaching to the pt and spouse? SATA - (correct Answer) - -review safe transfer strategies -develop a nutritional plan -help identify community support The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective? - (correct Answer) - pt who develop disease complications promptly received rehabilitation The nurse has received funding to design a health promotion project for African American women who are at risk for developing breast cancer. Which resource is most important in designing this program? - (correct Answer) - participation of community leaders in planning the program A pt with multiple injuries is being treated in the burn trauma unit just hours after the injuries occurred. The healthcare provider instructs the nurse to avoid auto contamination when performing dressing changes. Which intervention is most important for the nurse to implement? - (correct Answer) - use gown, mask, and gloves with dressing changes A pt is recovering in the critical care unit following a cardiac cath. IV nitro and

heparin are infusing. The pt is sedated but responds to instructions. After changing positions, the pt complains of pain at the right groin insertion site. What action should the nurse implement? - (correct Answer) - Stimulate the pt to take deep breaths Prior to obtaining a trapeze bar for a pt with limited mobility, which pt assessment is most important for the nurse to obtain? - (correct Answer) - upper body muscle strength While the nurse is assessing an older pt fall risk, the pt reports living at home alone and never falling. Which action should the nurse take? - (correct Answer) - Continue to obtain pt data needed to complete the fall risk survey The nurse is feeding an older adult who was admitted with aspiration pneumonia. The pt is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement? - (correct Answer) - Teach coughing and deep breathing exercises The nurse is teaching the pt about home care after surgery for an ileal conduit placement. When reviewing the information, which statement should the nurse recognize as needing additional education? - (correct Answer) - Empty the pouch when it is half full. A 12 week gestation is admitted to the antepartum unit with a dx of hyperemesis gravidarum. Which action is most important for the nurse to implement? - (correct Answer) - initiate prescribed IV fluids A pt with dyspnea is being admitted to the medical unit. To best prepare for the pt arrival, the nurse should ensure that the pt bed is in which position? - (correct Answer) - Picture with the bed sitting up A pt who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure. In preparing the pt for the procedure, which intervention has the highest priority? - (correct Answer) - Instruct pt to write down questions While caring for a pt post operative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the provider, the nurse should review which of the pt lab values? - (correct Answer) - culture for sensitive organisms A pt with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO every 12hrs. When the client requests an afternoon snack, which dietary choice should the nurse provide? - (correct Answer) - Cinnamon apple sauce An older male reporting abd pain is admitted from a facility. It has been 7 days since his last BM and his abd is distended, and he just vomited 150ml of dark brown emesis. In what order should the nurse implement these interventions? - (correct Answer) - Send emesis to lab

developing a teaching plan, the nurse should teach the parents to report which sign of overdose? - (correct Answer) - Bradycardia The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel working on a rehab unit. The UAP asks the nurse how to safely move a physically disabled pt from the... wheelchair to the bed. Which action should the nurse recommend? - (correct Answer) - Place the pt locked wheelchair on the pt strong side next to the bed The nurse has completed the diet teaching of a client who is being discharged following tx of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the pt indicates that the teaching was effective? - (correct Answer) - A tuna fish sandwich with chips and ice cream When conducting diet teaching for a pt who was dx with a myocardial infarction, which snack foods should the nurse encourage the pt to eat? SATA - (correct Answer) - Fresh Turkey slices and berries chick bouillon soup and toast raw unsalted almonds and apples A pt taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first? - (correct Answer) - Observe the appearance of the stool A pt is dx with Meniere's disease. Which problem should the nurse identify as most important in the plan of care? - (correct Answer) - Risk for injury related to vertigo A new nurse preparing to irrigate an IV catheter is attaching a 24 gauge needle. Which action should the charge nurse implement? - (correct Answer) - Suggest the nurse use 20g needle A nurse working on an Endocrine Unit should see which client first? - (correct Answer) - A pt taking corticosteroids who has become disoriented in the last two hours. After an older pt receives tx for drug toxicity the healthcare provider prescribes a 24 hr creatinine clearance, the nurse notes that the pt serum creatinine is 0.3mg. Which action should the nurse implement? - (correct Answer) - Notify the healthcare provider of the results An older adult pt with Systemic inflammatory syndrome (SIRS) has a temp of 101.8, HR of 110, and RR of 24 breaths/min. Which additional finding is most important to report to the healthcare provider? - (correct Answer) - Serum Creatinine of 2mg/dl A pt in the third trimester of pregnancy reports that she feels some lumpy places in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What actions should the nurse take? - (correct Answer) - Explain that this is normal recreation and can be assessed at the next visit.

A pt presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge. Which action should the nurse take first? - (correct Answer) - begin continuous fetal monitoring The mother of a 2 day old infant girl expresses concern about a flea bite type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer? - (correct Answer) - This is a common newborn rash that will resolve after several days. When assessing a recently delivered mom that her vaginal bleeding is more than expected. Which factor in this history is related to this finding? - (correct Answer) - She is a gravid 6 para 5. The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After administering surfactant, which assessment is most important for the nurse to monitor? - (correct Answer) - Arterial blood gas A pt who gave birth 48 hours ago has decided to bottle feed teh infant. During the assessment, the nurse observes that both breasts are swollen, warm and tender on palpation. Which instruction should the nurse provide? - (correct Answer) - Apply ice to the breast for comfort. The nurse is providing discharge teaching to the parents of a 13 month old child who underwent repair for an atrial septal defect. The healthcare provider prescribes aspirin and an antibiotic for the first 6 months postoperatively to prevent infective endocarditis. What information is most important for the nurse discuss with the parents about the child's recovery and prevention of IE. - (correct Answer) - Brush the child's teeth everyday and ensure the child receives regular dental follow up. A pt who is admitted with complications related to hypopituitarism is diaphoretic and hypotensive. Which assessment finding warrants immediate intervention by the nurse? - (correct Answer) - Lethargy The nurse identifies an electrolyte imbalance, a weight gain of 4.4lbs in 24 hours and an elevated central venous pressure for a pt with full thickness burns. Which intervention should the nurse implement? - (correct Answer) - Auscultate for irregular heart rate. A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presenting with which symptoms require the most immediate intervention by the nurse? - (correct Answer) - Chest discomfort one hour after consuming a large spicy meal. Which self care measure is most important to include in the plan of care of a pt recently diagnosed with type 2 diabetes mellitus? - (correct Answer) - blood glucose monitoring. In assessing a pt with type 1 diabetes mellitus, the nurse notes that the client's

An adult client is admitted to the ED after falling from a ladder. While waiting to have a CT scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the pt asks for something stronger. Which intervention should the nurse implement? - (correct Answer) - Explain the reason for using only non-narcotics The nurse is providing care for a pt with severe peripheral arterial disease. The pt reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding? - (correct Answer) - Offer cold packs when pain occurs When taking a health history, which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency? - (correct Answer) - History of intermittent claudication the nurse assesses a pt being treated for Herpes Zoster (Shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? SATA - (correct Answer) - Functional ability skin integrity pain scale A young male client is admitted to rehabilitation following a right above the knee amputation for a severe traumatic injury. He is in the commons room and anxiously calls out to the nurse, stating that his right foot is aching. The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement? - (correct Answer) - encourage discussion of feelings about the loss of his limb The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately? - (correct Answer) - Test the fluid on the dressing for glucose An older client with a long history of coronary artery disease, hypertension, and heart failure arrives in the ED with respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expect with the acute HR? - (correct Answer) - Reduced preload. A young adult visits the clinic reporting symptoms associated with gastritis. Which information in the pt history is most important for the nurse to address in the teaching? - (correct Answer) - consume 10 or more drinks of alcohol every weekend. The nurse completed the admission assessment of a 3-year-old who is admitted with bacterial meningitis and hydrocephalus. Which assesses evidence that the child is experiencing increased intracranial pressure. - (correct Answer) - sluggish and unequal pupillary responses

A teenager presents to the emergency dept with palpitations after vaping at a party. The pt is anxious, fearful, and hyperventilating. The nurse anticipates the developing acid base imbalance? - (correct Answer) - respiratory alkalosis Which intervention should the nurse include in the plan of care for a child with tetanus? - (correct Answer) - minimize the amount of stimuli in the room The nurse is caring for a 24 month old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not yet spoken two word phrases. Which assessment should the nurse administer? - (correct Answer) - The modified checklist for Autism A client fell in the bathroom when left unattended by the UAP. Which information should the nurse include in the pt health record? - (correct Answer) - The pt fell sustaining a fracture to the left hip the nurse is caring for a group of clients with the help of a PN. Which nursing actions should the nurse assign to the PN? - (correct Answer) - Administer a dose of insulin per sliding scale with type 2 diabetes mellitus Perform daily surgical dressing change for a pt who had an abdominal hysterectomy Obtain postoperative vital signs for a pt one day post op. A UAP is assigned to ambulate a pt with influenza who has droplet precautions implemented. The UAP requests a change in assignment, stating the reason of having not been fitted yet for a N95 respirator mask. Which action should the nurse take? - (correct Answer) - Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client. When providing patient care, the nurse sees a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision making process in response to the problem and clinical question is evidence- based. When gathering evidence, which consideration is most important? - (correct Answer)

  • Relevance to the situation The nurse is auscultating a pt lung sounds. Which description should the nurse use to document this sound? - (correct Answer) - High pitched or fine crackles When admitting a pt with a dx of transient ischemic attack (TIA), which intervention is most important for the nurse to include in the client's plan of care? - (correct Answer) - Initiate neurological monitoring every 2 hours The nurse is developing a plan of care for a pt who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? - (correct Answer) - The pt blood pressure readings will be less than 160/ Prior to surgery, written consent must be obtained. Which is the nurse's legal responsibility with regard to obtaining written consent? - (correct Answer) -

with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain? - (correct Answer) - When the pt last took drugs for bipolar disorder The nurse is providing care for a pt with schizophrenia who receives haloperidol decanoate 75 mg intramuscularly every 4 weeks. The pt begins developing puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement? - (correct Answer) - Complete abnormal involuntary movement scale A pt with postpartum depression, who is admitted to the behavioral health unit refuses to leave her room or eat meals. In addition to maintaining physical safety, which short term goal should the nurse include in the plan of care? - (correct Answer) - Attends one group activity per day The psychiatric nurse is caring for pts on an adolescent unit. Which client requires the nurse's immediate attention - (correct Answer) - An 18 year old pt with antisocial behavior who is being yelled at by other pts. The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching? - (correct Answer) - Practice using muscle relaxation techniques A preschool aged boy is admitted to the pediatric unit following successful resuscitation from a near drowning incident. While providing care to the child, the nurse begins with the brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take? - (correct Answer)

  • Ask the older brother how he felt during the incident. The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)? A. Tachycardia and tachypnea B. Sluggish and unequal pupillary responses C. Increased head circumference and bulging fontanels D. Blood pressure fluctuations and syncope - (correct Answer) - B. Sluggish and unequal pupillary responses A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse?

A. Abdominal pain decreases when lying supine B. Pain lasts an hour and leaves the abdomen tender C. Right upper quadrant pain refers to right scapula D. Drinks alcohol until intoxicated at least twice weekly. - (correct Answer) - A. Abdominal pain decreases when lying supine A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? A. Instructions about how much fluid the child should drink daily. B. Signs of addiction to opioid pain medications C. Information about non-pharmaceutical pain relief measures D. Referral for social services for the child and family - (correct Answer) - A. Instructions about how much fluid the child should drink daily To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select the location on the image with a red dot). - (correct Answer) - I placed the red dot on the base of the neck on the right side After receiving report on an inpatient acute care unit, which client should the nurse assess first? A. The client with an obstruction of the large intestine who is experiencing abdominal distention B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity - (correct Answer) - D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base imbalance? A. Respiratory acidosis B. Metabolic alkalosis C. Metabolic acidosis

C. Tell the older brother that he seems depressed D. Commend the older brother for his heroic actions - (correct Answer) - B. Ask the older brother how he felt during the incident A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take? A. Encourage the client to use cooler water and apply calamine lotion after soaking B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief C. Suggest that the client take brief showers and apply oil-based lotion after showering D. Explain that the symptoms are caused by liver damage and cannot be relieved - (correct Answer) - A. Encourage the client to use cooler water and apply calamine lotion after soaking An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expected in the client with acute HF? A. Increased cardiac contractility B. Reduced preload C. Relaxed vascular tone D. Decreased afterload - (correct Answer) - B. Reduced preload Which intervention should the nurse include in the plan of care for a child with tetanus? A. Encourage coughing and deep breathing B. Minimize the amount of stimuli in the room C. Reposition from side to side every hour D. Open window shades to provide natural light - (correct Answer) - B. Minimize the amount of stimuli in the room An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?

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 - (correct Answer) - C. Had a cold and ear infection for the past two days A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? A. The impending signs of death should be documented B. The client's status should be conveyed to the chaplain C. The client's need for pain medication should be determined D. The nurse manager should be updated on the client's status - (correct Answer) - C. The client's need for pain medication should be determined Which self care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus? A. Self-injection techniques B. Blood glucose monitoring C. Diabetic diet meal planning D. A realistic exercise plan - (correct Answer) - B. Blood glucose monitoring A client who gave birth 48 hours ago has decided to bottle feed the infant. During the assessment, the nurse observes that both breasts are swollen, warm, and tender on palpation. Which instruction should the nurse provide? A. Apply ice to the breasts for comfort B. Wear a loose-fitting bra during the day to prevent nipple irritation C. Run warm water over breasts D. Express small amounts of milk from the breasts to relieve pressure - (correct Answer) - A. Apply ice to the breasts for comfort The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply) A. Avoid range of motion exercises

reaction immediately D. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion - (correct Answer) - B. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the plan of care? A. Assess warmth of extremities B. Keep head of bed raised 45 degrees C. Monitor blood glucose level D. Maintain strict intake and output - (correct Answer) - D. Maintain strict intake and output A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use? A. Ask the client to describe the pain B. Observe body language and movement C. Identify effective pain relief measures D. Provide a numeric pain scale - (correct Answer) - A. Ask the client to describe the pain A client presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge. Which action should the nurse take first? A. Start an intravenous infusion B. Administer oxygen via facemask C. Perform a vaginal exam D. Begin continuous fetal monitoring - (correct Answer) - D. Begin continuous fetal monitoring A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide? A. Consume a high protein diet B. Increase physical activity C. Take vitamin supplements

D. Obtain a prostate-specific antigen blood level test - (correct Answer) - B. Increase physical activity The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1, mL to be infused intravenously over 4 hours. The IV administration set delivers 10gtt/mL. How many gtt/minute should the nurse regulate the infusion? (Round to the nearest whole number) - (correct Answer) - 42 gtt/min Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care? A. observe color of urine B. Measure body temperature C. Assess skin turgor D. Check for pedal edema - (correct Answer) - A. Observe color of urine A client fell in the bathroom when left unattended by the unlicensed assistive personnel (UAP). Which information should the nurse include in the client's health record? A. The UAP left the client to assist another client B. The last time client was assisted to the bathroom C. The unit was understaffed when the client fell D. The client fell sustaining a fracture to the left hip - (correct Answer) - D. The client fell sustaining a fracture to the left hip The nurse is reviewing the diagnostic tests prescribed for a client with a positive skin test. Which subjective findings reported by the client supports the diagnosis of tuberculosis? A. Barking cough and vomiting B. Mucopurulent cough and night sweats C. Dry cough and chest tightness D. Chronic cough and fatty stools - (correct Answer) - B. Mucopurulent cough and night sweats In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client become lethargic. Which assessment data should the nurse obtain next?

D. Administer intravenous diuretics - (correct Answer) - A. Obtain sputum sample A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? (descending order) - (correct Answer) - 1. Observe breathing patterns

  1. Assess blood pressure
  2. Measure body temperature
  3. Palpate for pedal edema A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation? A. Potassium 3.5 mEq/L B. Fingertips feel numb C. Sodium 135 mEq/L D. Cervical spine stiffness - (correct Answer) - B. Fingertips feel numb An older client is brought to the ED with a sudden onset of confusion that occurred after experiencing a fall at home. The client's daughter, who has power of attorney, has brought the client's prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR communication? A. currently prescribed medications B. Client's healthcare power of attorney C. Increasing confusion of the client D. Fall at home as reason for admission - (correct Answer) - C. Increasing confusion of the client The nurse identifies an electrolyte imbalance, a weight gain of 4.4lbs (2kg) in 24 hours and an elevated central venous pressure for a client with full thickness burns. Which intervention should the nurse implement? A. Auscultate for irregular heart rate B. Review arterial blood gases results C. Measure ankle circumference D. Document abdominal girth - (correct Answer) - A. Auscultate for irregular heart rate The nurse is caring for a group of clients with the help of a practical nurse (PN).

Which nursing actions should the nurse assign to the PN? (Select all that apply) A. Administer a dose of insulin per sliding scale for a client with Type 2 DM B. Start the second blood transfusion for a client 12 hours following a BKA C. Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperatively D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy E. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty - (correct Answer) - A. Administer a dose of insulin per sliding scale for a client with Type 2 DM D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy E. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity? A. Core strengthening B. Aerobic exercise C. Weight-bearing exercise D. Muscle stretching and toning - (correct Answer) - B. Aerobic exercise A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse? A. CT scan that was performed 6 months earlier B. Metal hip prosthesis was placed 20 years ago C. Report of client's sobriety for the last 5 years D. Takes metformin for type 2 diabetes mellitus - (correct Answer) - D. Takes metformin for type 2 diabetes mellitus A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (A1C) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale of insulin aspart every 6h are prescribed. What actions should the nurse include in this client's plan of care? (Select all that apply)