EXIT HESI Comprehensive B Evolve Practice
Questions and Answers
1. The nurse is caring for a client with a cerebrovascular
accident (CVA) who is rece... [Show More] iving 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).
2. 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).
3. 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).
4. 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.
5. 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).
6. 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.
7. 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).
8. 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).
9. 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).
10. Which intervention should be included in the plan of
care for a client admitted to the hospital with ulcerative
colitis? A.Administer stool softeners.
B.Place the client on fluid restriction.
C.Provide a low-residue diet.
D.Add a milk product to each meal.: C Rationale:
A low-residue diet (C) will help decrease symptoms of diarrhea,
which are clinical manifestations of ulcerative colitis. (A, B, and D)
are contraindicated and could worsen the condition.
11. The nurse is caring for a client with deep vein
thrombosis who is on a continuous IV heparin infusion. The
activated partial prothrombin time (aPTT) is 120 seconds.
Which action should the nurse take?
A.Increase the rate of the heparin infusion using a
nomogram.
B.Decrease the heparin infusion rate and give vitamin K IM.
C.Continue the heparin infusion at the current prescribed
rate.
D.Stop the heparin drip and prepare to administer protamine
sulfate.: D Rationale:
An aPTT more than 100 seconds is a critically high value;
therefore, the heparin should be stopped. The antidote for heparin
is protamine sulfate (D). Increasing the rate would increase the
risk for hemorrhage (A). The infusion should be stopped, and
vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the
infusion at the current rate would increase the risk for hemorrhage
(C).
12. While assessing a client with recurring chest pain, the
unit secretary notifies the nurse that the client's health care
provider is on the telephone.
What action should the nurse instruct the unit secretary to
implement? A.Transfer the call into the room of the client.
B.Instruct the secretary to explain reason for the call.
C.Ask another nurse to take the phone call.
D.Ask the health care provider to see the client on the unit.:
C Rationale:
Another nurse should be asked to take the phone call (C), which
allows the nurse to stay at the bedside to complete the assessment
of the client's chest pain. (A and B) should not be done during an
acute change in the client's condition. Requesting the health care
provider (D) to come to the unit is premature until the nurse
completes assessment of the client's status.
13. Which instruction(s) should the nurse include in the
discharge teaching plan of a male client who has had a
myocardial infarction and who has a new prescription for
nitroglycerin (NTG)? (Select all that apply.)
A.Keep the medication in your pocket so that it can be
accessed quickly.
B.Call 911 if chest pain is not relieved after one nitroglycerin.
C.Store the medication in its original container and protect it
from light.
D.Activate the emergency medical system after three doses
of medication. E.Do not use within 1 hour of taking sildenafil
citrate (Viagra).: B,C Rationale:
Emergency action should be taken if chest pain is not relieved after
one nitroglycerin tablet (B). The medication should be kept in the
original container to protect from light (C). Keeping the medication
in the shirt pocket provides an environment that is too warm (A).
The newest guidelines recommend calling 911 after one
nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin and
other nitrates should never be taken with Viagra (E).
14. The nurse prepares to administer 3 units of regular
insulin and 20 units of NPH insulin subcutaneously to a
client with an elevated blood glucose level.
Which procedure is correct?
A.Using one syringe, first insert air into the regular vial and
then insert air into the NPH vial.
B.Using one syringe, add the regular insulin into the syringe
and then add the NPH insulin.
C.Avoid combining the two insulins because incompatibility
could cause an adverse reaction.
D.Administer the regular insulin subcutaneously and then
give the NPH IV to prevent a separate stick.: B Rationale:
The regular or "clear" insulin should be withdrawn into the syringe
first, followed by the NPH (B). Air should first be injected into the
NPH vial and then air should be inserted into the regular vial (A).
NPH and regular insulin are compatible, and combining will reduce
the number of injections (C). The insulin is ordered subcutaneously
and NPH cannot be given IV (D).
15. An 8-year-old child is receiving digoxin (Lanoxin) for
congestive heart failure (CHF). In assessing the child, the
nurse finds that her apical heart rate is 80 beats/min, she
complains of being slightly nauseated, and her serum
digoxin level is 1.2 ng/mL. What action should the nurse
take?
A.Because the child's heart rate and digoxin level are within
normal range, assess for the cause of the nausea.
B.Hold the next dose of digoxin until the health care provider
can be notified because the serum digoxin level is elevated.
C.Administer the next dose of digoxin and notify the health
care provider that the child is showing signs of toxicity.
D.Notify the health care provider that the child's pulse rate is
below normal for her age group.: A Rationale:
Nausea and vomiting are early signs of digoxin toxicity. However,
the normal resting heart rate for a child 8 to 10 years of age is 70
to 110 beats/min and the therapeutic range of serum digoxin levels
is 0.5 to 2 ng/mL. Based on the objective data, (A) is the best of the
choices provided because the serum digoxin level is within normal
levels. (B) is not warranted by the data presented. The digoxin level
is within the therapeutic range and the child is not showing signs of
toxicity (C). The child's pulse rate is within normal range for her age
group (D).
16. The nurse prepares to administer acetaminophen oral
suspension to a child who weighs 66 pounds. The
prescription reads: Administer 15 mg/kg every 6 hours by
mouth. The Tylenol is available 150 mg/5 ml. Which is the
correct dosage indicated on the image?
A.30ml B.15ml
C.10ml
D.5ml: B Rationale:
66 lb/(2.2 kg/lb) = 30 kg
30 kg × (15 mg/kg) = 450 mg (5 mL/150 mg) × 450 mg = 15 mL or
(450 mg/150 mg) × 5 mL = 15 mL
17. When assessing the laboratory findings of a 38-year-old
client with tuberculosis who is taking rifampin (Rifadin),
which laboratory finding would be most important to report
to the primary health care provider immediately?
A.Orange-colored urine
B.Potassium level, 4.9 mEq/L
C.Elevated liver enzyme levels
D.Blood urea nitrogen (BUN) level, 12 mg/dL: C Rationale:
Rifampin can cause hepatoxicity, so elevated liver enzyme levels
need to be closely monitored and reported to the health care
provider (C). Orange discoloration of the urine is an expected side
effect of this medication (A). The potassium level (B) is normal. A
BUN level of 12 mg/dL is within defined parameters (D).
18. A client is receiving propylthiouracil (PTU) prior to
thyroid surgery. Which diagnostic test results indicate that
the medication is producing the desired effect?
A.Increased hemoglobin and hematocrit levels
B.Increased serum calcium level
C.Decreased white blood cell (WBC) count
D.Decreased triiodothyronine (T3) and thyroxine (T4) levels:
D Rationale:
Propylthiouracil (PTU) is an adjunct therapy used to control
hyperthyroidism by inhibiting the production of thyroid hormones
(D). It is often prescribed in preparation for thyroidectomy or
radioactive iodine therapy. It is does not affect (A). (B) must be
monitored after surgery in case the parathyroid glands were
removed, but preoperative PTU does not increase the serum
calcium level. If the client has an infection preoperatively,
antibiotics will be given and (C) monitored.
19. The nurse teaches a class on bioterrorism. Which
method(s) of transmission is(are) possible with the biologic
agent Bacillus anthracis (Anthrax)?
(Select all that apply.)
A.Inhalation of powder form
B.Handling of infected animals
C.Spread from person to person through coughing
D.Eating undercooked meat from infected animals E.Direct
cutaneous contact with the powder: A,B,D,E Rationale:
Anthrax can be transmitted by the inhalation, cutaneous, and
digestive routes (A, B, D, and E); however, the disease is not
spread from person to person (C).
20. The nurse assesses a woman in the emergency room
who is in her third trimester of pregnancy. Which finding(s)
is(are) indicative of abruptio placentae? (Select all that
apply.) A.Dark red vaginal bleeding
B.Rigid boardlike abdomen
C.Soft abdomen on palpation
D.Complaints of severe abdominal pain E.Painless bright red
vaginal bleeding: A,B,D Rationale:
These are all signs of abruptio placentae (A, B, and D). The others
are signs of placenta previa (C and E).
21. Which vital sign in a pediatric client is most important to
report to the primary health care provider?
A.Newborn with a heart rate of 140 beats/min
B.Three-year-old with a respiratory rate of 28 breaths/min
C.Six-year-old with a heart rate of 130 beats/min
D.Twelve-year-old with a respiratory rate of 16 breaths/min: C
Rationale:
The normal heart rate for a 6- to 10-year-old is 70 to 110 beats/min
(C). The others are all within normal range for those ages (A, B,
and D).
22. Which finding should be reported to the primary health
care provider when caring for a client who has a continuous
bladder irrigation after a transurethral resection of the
prostate gland (TURP)?
A.The client reports a continuous feeling of needing to void.
B.Urinary drainage is pink 24 hours after surgery.
C.The hemoglobin level is 8.4 g/dL 3 days postoperatively.
D.Sterile saline is being used for bladder irrigation.: C
Rationale:
A hemoglobin level of 8.4 g/dL is abnormally low and may indicate
hemorrhage (C).
The others are all expected findings after a TURP (A, B, and D).
23. Which of the following cardiac rhythms is represented in
the image?
A.Normal sinus rhythm
B.Sinus tachycardia
C.Ventricular fibrillation D.Atrial fibrillation: C Rationale:
Ventricular fibrillation (C) is a life-threatening arrhythmia
characterized by irregular undulations of varying amplitudes. (A, B,
and D) are not represented in the image. 24. An adult client with
a medical diagnosis of substance abuse and schizophrenia
was recently switched from oral fluphenazine HCl (Prolixin) to
IM fluphenazine decanoate (Prolixin Decanoate) because of
medication noncompliance. What should the nurse teach the
client and family about this change in medication regimen?
A.Long-acting medication is more effective than daily
medication.
B.A client with substance abuse must not take any oral
medications.
C.There will continue to be a risk of alcohol and drug
interaction.
D.Support groups are only helpful for substance abuse
treatment.: C Rationale:
Alcohol enhances the side effects of Prolixin. The half-life of
Prolixin PO is 8 hours, whereas the half-life of the Prolixin
Decanoate IM is 2 to 4 weeks. Therefore, the side effects of
drinking alcohol are far more severe when the client drinks alcohol
after taking the long-acting Prolixin Decanoate IM (C). (A, B, and
D) provide incorrect information.
25. A client comes to the obstetric clinic for her first prenatal
visit and complains of feeling nauseated every morning. The
client tells the nurse, "I'm having second thoughts about
wanting to have this baby." Which response is best for the
nurse to make?
A."It's normal to feel ambivalent about a pregnancy when you
are not feeling well."
B."I think you should discuss these feelings with your health
care provider."
C."How does the father of your child feel about your having
this baby?" D."Tell me about these second thoughts you are
having about this pregnancy.": D Rationale:
Although ambivalence is normal during the first trimester, (D) is
the best nursing response at this time. It is reflective and keeps
the lines of communication open. (A) is not the best response
because it offers false reassurance. (B) dismisses the client's
feelings. The nurse should use communication skills that
encourage this type of discussion, not shift responsibility to the
care provider. (C) may eventually be discussed, but it is not the
most important information to obtain at this time. 26. A nurse
performs an initial admission assessment of a 56-year-old
client. Which factor(s) would indicate that the client is at risk
for metabolic syndrome? (Select all that apply.)
A.Abdominal obesity
B.Sedentary lifestyle
C.History of hypoglycemia
D.Hispanic or Asian ethnicity E.Increased triglycerides:
A,B,D,E Rationale:
Metabolic syndrome is a name for a group of risk factors that
increase the risk for coronary artery disease, type 2 diabetes, and
stroke (A, B, D, and E). Hypoglycemia is not a risk factor for
metabolic syndrome (C).
27. The nurse administers regular insulin (human), 8 units
subcutaneously, to a client at 8:00 am, 30 minutes before
breakfast. At what time is the client most at risk for a
hypoglycemic reaction?
A.9:30 am
B.10:30 am
C.12:00 pm D.3:00 pm: B Rationale:
Regular insulin is short-acting and peaks between 2 and 3 hours
after administration
(B). The client is most at risk for a hypoglycemic reaction during the
peak times. (A, C, and D) are not high-risk times for the client to
experience hypoglycemia because they do not fall within the peak
time.
28. Which intervention is most important when caring for a
client immediately after electroconvulsive therapy
(ECT)?A.Reorient the client to surroundings. B.Assess blood
pressure every 15 minutes.
C.Determine if muscle soreness is present. D.Maintain a
patent airway.: D Rationale:
The client is typically unconscious immediately following ECT, and
nausea is a common side effect. The nurse should take measures
to prevent aspiration and maintain a patent airway (D). Patients
may be confused after ECT (A), but reorientation is not as high a
priority as the airway. Although vital signs should be assessed, the
airway is a higher priority (B). Muscle soreness is an expected
finding after ECT (C).
29. The nurse prepares to administer ophthalmic drops to a
client prior to cataract surgery. List the steps in the order that
they should be implemented from first step to final step.
A. Drop prescribed number of drops into conjunctival sac.
B. Wash hands and apply clean gloves.
C. Place dominant hand on the client's forehead.
D. Ask the client to close the eye gently.
A. C, B, A, D
B. B, C, A, D
C. A, B, D, CD. A, C, B, D: B Rationale:
Washing hands and applying gloves prior to procedure initiation
prevents the spread of infection (B). Placing the dominant hand on
the client's forehead (C) stabilizes the hand so the nurse can hold
the dropper 1 to 2 cm above the conjunctival sac and drop the
prescribed number of drops (A); asking the client to close the eye
gently helps distribute the medication (D).
30. A client with bipolar disorder is seen in the mental health
clinic for evaluation of a new medication regimen that
includes risperidone (Risperdal). The nurse notes that the
client has gained 30 lb in the past 3 months. Which
assessment is most important for the nurse to obtain?
A.Compliance with medication regimen
B.Current thyroid-stimulating hormone (TSH) level
C.Occurrence of mania or depression D.A 24-hour diet and
exercise recall: A Rationale:
Medication compliance (A) is most important for the treatment of
psychotic disorders and, because Risperdal is associated with
weight gain, it is probable that the client is complying with the
treatment plan. The TSH level (B) indicates thyroid function, which
regulates basal metabolic rate and influences weight. It is important
to obtain information about occurrences of mania and depression
(C) since the last visit, but if the client is compliant with the
medication regimen, these symptoms are likely to have been
controlled. Diet and exercise (D) should also be assessed, but
weight gain is a likely indicator of medication compliance.
31. The nurse is caring for a client with chronic renal failure
(CRF) who is receiving dialysis therapy. Which nursing
intervention has the greatest priority when planning this
client's care? A.Palpate for pitting edema.
B.Provide meticulous skin care.
C.Administer phosphate binders.
D.Monitor serum potassium levels.: D Rationale:
Clients with CRF are at risk for electrolyte imbalances, and
imbalances in potassium can be life threatening (D). One sign of
fluid retention is pitting edema (A), but it is an expected symptom
of renal failure and is not as high a priority as (D). (B and C) are
common nursing interventions for CRF but not as high a priority as
(D).
32. A client is admitted with a diagnosis of leukemia. This
condition is manifested by which of the following?
A.Fever, elevated white blood count, elevated platelets
B.Fatigue, weight loss and anorexia, elevated red blood cells
C.Hyperplasia of the gums, elevated white blood count,
weakness
D.Hypocellular bone marrow aspirate, fever, decreased
hemoglobin level: C Rationale:
Hyperplastic gums, weakness, and elevated white blood count are
classic signs of leukemia (C). (A, B, and D) state incorrect
information for symptoms of leukemia.
33. Which monitored pattern of fetal heart rate alerts the
nurse to seek immediate intervention by the health care
provider? A.Accelerations in response to fetal movement
B.Early decelerations in the second stage of labor
C.Fetal heart rate of 130 beats/min between contractions
D.Late decelerations with absent variability and tachycardia:
D Rationale:
Late decelerations indicate uteroplacental insufficiency and can
be indicative of complications. When occurring with absent
variability and tachycardia, the situation is ominous (D). 130
beats/min is an expected heart rate (C). The others are not as
critical (A and B).
34. Which disaster management intervention by the nurse is
an example of primary prevention?
A.Emergency department triage
B.Follow-up care for psychological problems
C.Education of rescue workers in first aid D.Treatment of
clients who are injured: C Rationale:
Primary prevention is aimed at preventing disease or injury.
Training rescue workers prior to a disaster is an example of
minimizing or preventing injury (C). (A) is an example of secondary
prevention. (B) is an example of tertiary prevention. (D) is an
example of secondary prevention.
35. The nurse is caring for a client who is experiencing
severe pain. The expected outcome the nurse writes for the
client reads, "The client will state my pain is less than 2 within
45 minutes after pain medication has been administered."
Formulating the expected outcome is an example of which
step in the nursing process?
A.Assessment
B.Planning
C.Implementation D.Evaluation: B Rationale:
Planning (B) allows the nurse to set goals for care and elicit the
expected outcome by identifying appropriate nursing actions.
Assessment, implementation, and evaluation are part of the care
for the client but are not the appropriate actions for formulating
the expected outcome (A, C, and D).
36. The nurse is planning the care for a client who is admitted
with syndrome of inappropriate antidiuretic hormone
secretion (SIADH). Which intervention(s) should the nurse
include in this client's plan of care? (Select all that apply.)
A.Salt-free diet
B.Quiet environment
C.Deep tendon reflex assessments
D.Neurologic checks E.Daily weights: B,C,D,E Rationale:
Correct responses are (B, C, D, and E). SAIDH results in water
retention and dilutional hyponatremia, which causes neurologic
changes when serum sodium levels are less than 115 mEq/L. The
nurse should maintain a quiet environment (B) to prevent
overstimulation and assess deep tendon reflexes (C) and perform
neurologic checks (D) to monitor for neurologic deterioration.
Daily weights (E) should be monitored to assess for fluid
overload. (A) would contribute to dilutional hyponatremia.
37. A client in the psychiatric setting with an anxiety disorder
reports chest pain. Which action should the nurse take first?
A.Administer an antianxiety medication PRN.
B.Assess the client's vital signs.
C.Notify the primary health care provider.
D.Determine coping mechanisms used in the past.: B
Rationale:
Although increased heart rate, palpitations, and chest pain may
be caused by anxiety, it is important that the nurse assess the
patient and rule out physiologic causes (B). Nonpharmacologic
measures should be taken first (A). (C and D) may be considered
but are not as high priority as the initial physiologic assessment.
38. The charge nurse observes a student nurse enter the
room of a client who is prescribed airborne precautions. The
application of which personal protective equipment by the
student indicates a correct understanding of this precaution?
A.Surgical mask, clean gloves, and gown
B.Properly fitted N95 respirator or mask
C.Sterile gloves and gown
D.Goggles, clean gloves, and gown: B Rationale:
The use of personal protective equipment (PPE) for airborne
precautions includes a properly prefitted N95 respirator or mask
(B). (A, C and D) do not provide the appropriate respiratory
equipment for airborne precautions. A surgical mask is used for
preventing transmission of droplet precautions.
39. The nurse empties a client's urinary drainage from an
indwelling Foley catheter. Which finding should be reported
to the primary health care provider?
A.Ammonia odor is noted when the catheter is emptied.
B.240 mL of urinary output is produced in 12 hours.
C.A 16-French catheter was used for an adult female.
D.Drainage system is hanging below the level of the bladder.:
B Rationale:
An expected finding is between 400 and 750 mL in 12 hours =
average of 30 mL/hr (B). Ammonia odor is an expected finding
(A). Size 14- to 18-French catheters are common sizes used in
the adult female (C). Below the level of the bladder is the correct
position for the drainage bag (D).
40. An adult female who presents at the mental clinic
trembling and crying becomes distressed when the nurse
attempts to conduct an assessment. She complains about
the number of questions that are being asked, which she is
convinced are going to cause her to have a heart attack.
What action should the nurse take?
A.Take the client's blood pressure and reassure her that
questioning will not cause a heart attack.
B.Explain that treatment is based on information obtained in
the assessment. C.Encourage the client to relax so that she
can provide the information requested.
D.Empower the client to share her story of why she is here at
the mental health clinic.: D
Rationale:
The client is exhibiting signs of moderate anxiety, which include
voice tremors, shakiness, somatic complaints, and selective
inattention. (D) is the best method for addressing this client's level
of anxiety by creating a shared understanding of the client's
concerns. Although assessment of her blood pressure (A) might be
a worthwhile intervention, reassuring her that questioning will not
cause a heart attack (A) is argumentative. (B) suggests that
treatment cannot be provided without the information, which is
manipulative. Asking the client to relax (C) is likely to increase her
anxiety.
41. Which information is most concerning to the nurse when
caring for an older client with bilateral cataracts?
A.States having difficulty with color perception
B.Presents with opacity of the lens upon assessment
C.Complains of seeing a cobweb-type structure in the visual
field D.Reports the need to use a magnifying glass to see
small print: C Rationale:
Visualization of a cobweb- or hairnet-type structure is a sign of a
retinal detachment, which constitutes a medical emergency.
Clients with cataracts are at increased risk for retinal detachment
(C). Distorted color perception (A), opacity of the lens (B), and
gradual vision loss (D) are expected signs and symptom of
cataracts, but do not need immediate attention.
42. Which intervention(s) should be performed by the nurse
when caring for a
woman in the fourth stage of labor? (Select all that apply.)
A.Maintain bed rest for the first 6 hours after delivery.
B.Palpate and massage the fundus to maintain firmness.
C.Have client empty bladder if fundus is above umbilicus.
D.Check perineal pad for color and consistency of lochia.
E.Apply ice pack or witch hazel compresses to the
perineum.: B,D,E Rationale:
The fundus should be palpated and massaged frequently to
prevent hemorrhage (B). The lochia should be assessed to detect
for hemorrhage (D) and ice packs and witch hazel can decrease
edema and discomfort (E). Bed rest is only recommended for the
first 2 hours (A). A full bladder is suspected if the fundus is deviated
to the right or left of the umbilicus (C).
43. The nurse prepares to administer amoxicillin clavulanate
potassium (Augmentin) to a child weighing 15 kg. The
prescription is for 15 mg/kg every 12 hours by mouth. How
many milliliters should the nurse administer when supplied as
below?
A.0.5
B.1.8
C.5
D.9: D
Rationale:15 mg/kg × 15 kg = 225 mg to be administered
Supply = 125 mg/5 mL
(5 mL/125 mg) × 225 mg = 9 mL or
(225 mg/125 mg) × 5 ml = 9 mL
44. Which data obtained during a respiratory assessment for a
78-year-old client is most important to report to the primary
health care provider?
A.Auscultation of vesicular breath sounds
B.Pulse oximetry reading of 89%
C.Arterial Pao2 of 86%
D.Resonance on percussion of the lungs: B Rationale:
An oxygen saturation lower than 90% indicates hypoxia (B). (A, C,
and D) are all normal findings.
45. When caring for a client with a tracheostomy, which
intervention should the nurse delegate to the unlicensed
assistive personnel (UAP)? A.Teach the family about signs
and symptoms of hypoxia.
B.Take the vital signs and obtain an O2 saturation level.
C.Evaluate the need for tracheal suctioning.
D.Revise the plan of care to include tracheostomy care.: B
Rationale:
The nurse may delegate obtaining vital signs and O2 saturation;
however, the nurse is responsible for following up on any reported
data (B). (A, C, and D) are all part of the nursing process and
should not be delegated under the nurse's scope of practice.
46. The nurse is caring for a client who develops ventricular
fibrillation. Which action should the nurse take first?
A.Administer epinephrine.
B.Defibrillate immediately.
C.Bolus with isotonic fluid.
D.Notify the health care provider.: B Rationale:
Defibrillation is the first and most effective emergency treatment for
ventricular fibrillation (B). The others may follow the first action (A,
C, and D).
47. A client at 32 weeks of gestation is hospitalized with
preeclampsia, and magnesium sulfate is prescribed to
control the symptoms. Before the next dose of MgSO4 is
given, which assessment finding indicates that the patient is
at risk for toxicity?
A.Deep tendon reflexes—decrease to 2+
B.100 mL of urine output in 4 hours
C.Respiratory rate decreases to 16 breaths/min D.Serum
magnesium level, 7.5 mg/dL: B Rationale:
Magnesium sulfate, a central nervous system (CNS) depressant,
helps prevent seizures, so (A) is a positive sign that the
medication is having a desired effect. The minimum urine output
expected for a repeat dose of magnesium sulfate is 30 mL/hr, so
100 mL of urine in 4 hours can lead to poor excretion of
magnesium, with a possible cumulative effect (B). A decreased
respiratory rate (C) indicates that the drug is effective. A
respiratory rate below 12 breaths/min indicates toxic effects. The
therapeutic level of magnesium sulfate for a PIH client is 4 to 8
mg/dL (D).
48. The nurse walks into the room and observes the client
experiencing a tonic-clonic seizure. Which intervention
should the nurse implement first? A.Restrain the client to
protect from injury.
B.Flex the neck to ensure stabilization.
C.Use a tongue blade to open the airway.
D.Turn client on the side to aid ventilation.: D Rationale:
Maintaining airway during a seizure is priority for safety (D). (A, B,
and C) are contraindicated during a seizure and may cause further
injury to the client.
49. When assessing safety for the older adult, which of the
following is of highest priority to the nurse?
A.The client has a cataract in the right eye.
B.The client is not married and lives alone.
C.The client lives in a two-story building.
D.The client reports a history of repeated falls.: D Rationale:
Risk assessment for falls is a critical element in caring for the older
adult. (A, B, and C) are important components in assessing client
risk, but a history of prior falls puts the older client at very high risk
for falling again (D).
50. The nurse expects a clinical finding of cyanosis in an infant
with which condition(s)? (Select all that apply.) A.Ventricular
septal defect (VSD)
B.Patent ductus arteriosis (PDA)
C.Coarctation of the aorta
D.Tetralogy of Fallot
E.Transposition of the great vessels: D,E Rationale:
Both tetralogy of Fallot and transposition of the great vessels are
classified as cyanotic heart disease, in which unoxygenated blood
is pumped into the systemic circulation, causing cyanosis (D and
E). The others are all abnormal cardiac conditions, but are
classified as acyanotic and involve left-to-right shunts, increased
pulmonary blood flow, or obstructive defects. (A, B, and C).
51. A nurse implements an education program to reduce hospital
readmissions for clients with heart failure. Which statement
by the client indicates that teaching has been effective?
A."I will not take my digoxin if my heart rate is higher than
100 beats/min."
B."I should weigh myself once a week and report any
increases."
C."It is important to increase my fluid intake whenever
possible." D."I should report an increase of swelling in my
feet or ankles.": D Rationale:
An increase in edema indicates worsening right-sided heart failure
and should be reported to the primary health care provider (D).
Digitalis should be held when the heart rate is lower than 60
beats/min (A). The client with heart failure should weigh himself or
herself daily and report a gain of 2 to 3 lb (B). An increase in fluid
can worsen heart failure (C).
52. Which action by the nurse is consistent with culturally
competent care?
A.Treating each client the same regardless of race or religion
B.Ensuring that all Native American clients have access to a
shaman
C.Understanding one's own world view in addition to the
client's
D.Including the family in the plan of care for older clients: C
The nurse should understand his or her own values and views to
prevent those values from being imparted to others, in addition to
understanding the client's cultural views (C). Treating every client
the same or assuming that all clients share the same values does
not exhibit cultural competence or sensitivity (A, B, and D).
53. The nurse enters the examination room of a client who has
been told by her health care provider that she has advanced
ovarian cancer. Which response by the nurse is likely to be
most supportive for the client?
A."I know many women who have survived ovarian cancer."
B."Let's talk about the treatments of ovarian cancer."
C."In my opinion I would suggest getting a second opinion."
D."Tell me about what you are feeling right now.": D
Rationale:
The most therapeutic action for the nurse is to be an active listener
and to encourage the client to explore her feelings (D). Giving false
reassurance or personal suggestions are not therapeutic
communication for the client (A, B, and C).
54. A client in an acute psychiatric setting asks the nurse if their
conversations will remain confidential. How should the nurse
respond?
A."The Health Insurance Portability and Accountability Act
(HIPAA) prevents me from repeating what you say."
B."You can be assured that I will keep all of our
conversations confidential because it is important that you
can trust me."
C."For your safety and well-being, it may be necessary to
share some of our conversations with the health care team."
D."I am legally required to document all of our conversations
in the electronic medical record.": C Rationale:
Some information, such as a suicide plan, must be shared with
other team members for the client's safety and optimal therapy (C).
HIPAA does not prevent a member of the health care team from
repeating all conversations, particularly if safety is an issue (A).
Ensuring a client that a conversation will remain confidential puts
the nurse at risk, particularly if safety is an issue (B). Although
pertinent information should be documented, the nurse is not
legally required to document all conversations with a client (D).
55. A 45-year-old female client is admitted to the psychiatric
unit for evaluation. Her husband states that she has been
reluctant to leave home for the last 6 months. The client has
not gone to work for a month, has been terminated from her
job, and has not left the house since that time. This client is
displaying symptoms of which disorder?
A.Claustrophobia
B.Acrophobia
C.Agoraphobia D.Necrophobia: C Rationale:
Agoraphobia (C) is the fear of crowds or of being in an open
place. (A) is the fear of being in closed places. (B) is the fear of
high places. (D) is an abnormal fear of death or bodies after
death. A phobia is an unrealistic fear associated with severe
anxiety.
56. The nurse reviews the comprehensive metabolic panel
for a client with an electrolyte imbalance. Which data
requires the most immediate intervention by the nurse?
A.Potassium level, 3.9 mEq/dL
B.Creatinine level,1.1 mg/dL
C.Sodium level, 125 mEq/L D.Calcium level, 9 mg/dL: C
Rationale:
The normal serum sodium level is 135 to 145 mEq/L (C). This value
indicates hyponatremia. Symptoms of hyponatremia include
nausea and vomiting, headache, confusion, and seizures, which
can be severe and need immediate attention. (A, B, and D) are all
within normal parameters.
57. The nurse anticipates administering Rho(D) immune
globulin (RhoGAM) to which individual(s)? (Select all that
apply.)
A.An Rh-negative woman who has had a miscarriage at 24
weeks
B.The father of a baby of an Rh-positive fetus
C.An Rh-negative mother after delivery of an Rh-positive
infant with a negative direct Coombs' test
D.An Rh-positive infant within 72 hours after birth
E.An Rh-negative mother with a negative antibody titer at 28
weeks: A,C,E Rationale:
(A, C, and E) are all candidates for RhoGAM. RhoGAM should
never be given to an infant or father (B and D).
58. Which nursing intervention should be implemented
postoperatively in an infant with spina bifida after repair of a
meningocele? A.Limit fluids to prevent infection to the
surgical site.
B.Place the infant in the prone position.
C.Provide a low-residue diet to limit bowel movements.
D.Cover sac with a moist sterile dressing.: B Rationale:
The infant should be placed in the prone position to alleviate
pressure on the surgical site, which is in the sacrum (B). Fluids
should be increased postoperatively to prevent dehydration (A). A
high-fiber diet should be implemented to prevent constipation (C). [Show Less]
