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HESI EXIT V1 - V6 EXAMS BUNDLE | VERIFIED DOCUMENTS
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2019 HESI EXIT V1 | Verified 100%
2019 HESI EXIT V1 1. Which information is a priority for the RN to reinforce to an older client after intravenous pylegraphy? A) Eat a light diet for the... [Show More] rest of the day B) Rest for the next 24 hours since the preparation and the test is tiring. C) During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease. The correct answer is D: Measure the urine output for the next day and immediately notify the health care provider if it should decrease. 2. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is: A) difference in the intake and output B) changes in the mucous membranes C) skin turgor D) weekly weight The correct answer is D: weekly weight 3. A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most important for the nurse to reinforce with the client? A) It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) B) It is critical to report promptly to your health care provider any findings of peptic ulcers c) Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors D) With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine The correct answer is B: It is critical to report promptly to your health care provider any findings of peptic ulcers. 4. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client’s blood pressure is increasing. Which action should the nurse take first? A) Check the protein level in urine B) Have the client turn to the left side C) Take the temperature D) Monitor the urine output The correct answer is B: Have the client turn to the left side 5. The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? A) Diminished bowel sounds B) Loss of appetite C) A cold, pale lower leg D) Tachypnea The correct answer is C: A cold, pale lower leg 6. The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? A) Nausea and vomiting B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius) C) Diffuse macular rash D) Muscle tenderness The correct answer is B: Fever of 103 degrees F (39.5 degrees C) 7. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? A) Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. B) This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate. C) After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days. D) The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort. The correct answer is A: Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. 8. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? A) Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes. B) In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness. * C) The flow of life is believed to flow through major pathways or nerve clusters in your body. D) By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over. The correct answer is C: The flow of life is believed to flow through major pathways or nerve clusters in your body. 9. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? A)It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes. B)In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain C) Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent D) Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to2 weeks The correct answer is C: Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent 10. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A) Side-lying on the left with the head elevated 10 degrees B) Side-lying on the left with the head elevated 35 degrees C) Side-lying on the right wil the head elevated 10 degrees D) Side-lying on the right with the head elevated 35 degrees The correct answer is A: Side-lying on the left with the head elevated 10 degrees 11. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? A) Light, pink urine B) occasional suprapubic cramping C) minimal drainage into the urinary collection bag D) complaints of the feeling of pulling on the urinary catheter The correct answer is C: minimal drainage into the urinary collection bag 12. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse? A) Relieve the nurse performing CPR B) Go get the code cart C) Participate with the compressions or breathing D) Validate the client's advanced directive The correct answer is C: Participate with the compressions or breathing 13. The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? A) Decreased urinary output B) Jugular vein distention C) Pleural effusion D) Bibasilar crackles The correct answer is B: Jugular vein distention 14. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) Can predispose to dysrhythmias B) May lead to oliguria C) May cause irritability and anxiety D) Sometimes alters consciousness The correct answer is A: Can predispose to dysrhythmias 15. A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? A) Flaccid paralysis B) Pupils fixed and dilated C) Diminished spinal reflexes D) Reduced sensory responses The correct answer is B: Pupils fixed and dilated 16. A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? A) ”I knew this would happen. I've been eating too much red meat lately." B) ”I really enjoyed my fishing trip yesterday. I caught 2 fish." C) ”I have really been working hard practicing with the debate team at school." D) ”I went to the health care provider last week for a cold and I have gotten worse." The correct answer is D: "I went to the doctor last week for a cold and I have gotten worse." 17. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? A) Hemoglobin level of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A heart rate between 140 to 160 The correct answer is B: Pale mucosa of the eyelids and lips 18. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses The correct answer is D: Pupil responses 19. Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? A) A young adult with a history of Down's syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness The correct answer is D: A preschooler with intermittent episodes of alertness 20. The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C) Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings The correct answer is D: Pale, thin arms and legs, uninterested in surroundings 21. As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss The correct answer is D: Hair loss 22. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to A) Call the health care provider immediately B) Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client's fluid intake The correct answer is B: Administer acetaminophen as ordered as this is normal at this time 23. A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be A) Cover the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Initiate intravenous therapy D) Administer pain medication The correct answer is B: Assess for dyspnea or stridor 24. Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A) I started my period and now my urine has turned bright red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn’t hurt when I went. The correct answer is D: I went to the bathroom and my urine looked very red and it didn’t hurt when I went. 25. A middle aged woman talks to the nurse in the health care provider’s office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? A) I am one out of every 4 women that get fibroids, and of women my age – between the 30s or 40s, fibroids occurs more frequently. B) My fibroids are noncancerous tumors that grow slowly. C) My associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention and constipation. D) Fibroids that cause no problems still need to be taken out. The correct answer is D: Fibroids that cause no problems still need to be taken out. 26. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? A) Stay with client and observe for airway obstruction B) Collect pillows and pad the side rails of the bed C) Place an oral airway in the mouth and suction D) Announce a cardiac arrest, and assist with intubation The correct answer is A: Stay with client and observe for airway obstruction 27. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor? A) FHT 168 beats/min B) Temperature 100 degrees Fahrenheit. C) Cervical dilation of 4 D) BP 138/88 The correct answer is A: FHT 168 beats/min 28. A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse’s initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? A) "I have a sharp pain in my chest when I take a breath." B) "I have been coughing up foul-tasting, brown, thick sputum." C) "I have been sweating all day." D) "I feel hot off and on." The correct answer is B: "I have been coughing up foul tasting, brown, thick sputum." 29. The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop B) Apical click C) Systolic murmur D) Split S2 The correct answer is A: S3 ventricular gallop 30. Which of these observations made by the nurse during an excretory urogram indicate a complicaton? A) The client complains of a salty taste in the mouth when the dye is injected B) The client’s entire body turns a bright red color C) The client states “I have a feeling of getting warm.” D) The client gags and complains “ I am getting sick.” The correct answer is B: The client’s entire body turns a bright red color 31. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest." B) "The tube will remove excess air from your chest." C) "The tube controls the amount of air that enters your chest." D) "The tube will seal the hole in your lung." The correct answer is B: "The tube will remove excess air from your chest." 32. The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7.30 D) Serum potassium 6 mEq/L The correct answer is D: Serum potassium 6 mEq/L 33. The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse’s immediate attention? A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms The correct answer is C: Dyspnea 34. The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? A) Breath sounds can be heard bilaterally B) Mist is visible in the T-Piece C) Pulse oximetry of 88 D) Client is unable to speak The correct answer is C: Pulse oximetry of 88 35. A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? A) drowsiness [Show Less]
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2020 HESI RN EXIT EXAM V2
2020 HESI EXIT V2 1) The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old... [Show More] infant and her 4 year-old child? A) "I strap the infant car seat on the front seat to face backwards." B) "I place my infant in the middle of the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen." C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year old naps on the sofa." D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." The correct answer is D: "I have the four year-old hold and help feed the four month-old a bottle in the kitchen 2) Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? A) Record the information on the chart B) Give information about advance directives C) Assume that this client wishes a full code D) Refer this issue to the unit secretary The correct answer is B: Give information about advance directives 3) A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to A) Maintain the airway B) Administer epinephrine 1:1000 as ordered C) Monitor for hypotension with shock D) Administer diphenhydramine as ordered The correct answer is B: Administer epinephrine 1:1000 as ordered. 4) Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? A) An infant with intermittent bulging anterior fontanel between crying episodes B) A toddler with severe deep abrasions over 98% of the body C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture D) A school-age child with singed eyebrows and hair on the arms The correct answer is B: A toddler with severe deep abrasions over 98% of the body. 5) When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse’s best action is to A) Change whichever item is incorrect to the correct information B) Use the bracelet and admission form until a replacement is supplied C) C) Notify the admissions office and wait to apply the bracelet D) Make a corrected identification bracelet for the client The correct answer is C: notify the admissions office and wait to apply the bracelet 6) The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? A) Leave the order for the oncoming staff to follow-up B) Contact the charge nurse for an interpretation C) Ask the pharmacy for assistance in the interpretation D) D) Call the provider for clarification The correct answer is D: Call the provider for clarification 7) An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to: A) check the carotid pulse B) deliver 5 abdominal thrusts C) give 2 rescue breaths D) open the client's airway The correct answer is D: open the client’s airway 8) A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? A) Ask the client if there are any breathing problems B) Have the client void as much as possible C) Check the vital signs D) Auscultate the lungs The correct answer is D: Auscultate the lungs 9) Following change-of-shift report on an orthopedic unit, which client should the nurse see first? A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago B) 20 year-old in skeletal traction for 2 weeks since a motorcycle accident C) C) 72 year-old recovering from surgery after a hip replacement 2 hours ago D) 75 year-old who is in skin traction prior to planned hip pinning surgery. The correct answer is C: 72 year-old recovering from surgery after a hip replacement 2 hours ago 10) A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? A) Why don’t we now have the client turn back to the left side. B) That was done correctly. Did you have any problems with the insertion? C) Let’s check to see if the suppository is in far enough. D) Did you feel any stool in the intestinal tract? The correct answer is B: That was done correctly. Did you have any problems with the insertion? 11) A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care? A) airborne precautions B) droplet precautions C) C) contact precautions D) Compromised host precautions The correct answer is C: contact precautions 12) The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? A) Void a little, clean the meatus, then collect specimen B) clean the meatus, begin voiding, then catch urine stream C) Clean the meatus, then urinate into container D) Void continuously and catch some of the urine The correct answer is B: clean the meatus, begin voiding, then catch urine stream 13) The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? A) spaghetti B) watermelon C) chicken D) tomatoes The correct answer is B: watermelon 14) A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? A) Look up the policy on needle sticks B) Contact employee health services C) Immediately wash the hands with vigor D) Notify the supervisor and risk management The correct answer is C: Immediately wash the hands with vigor 15) As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? A) Ask the student: "What did you forget to do?” B) Stop. Tell me why aspiration is needed. C) Loudly state: “You forgot to aspirate.” D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.” The correct answer is D: Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.” 16) A client with Guillain Barre is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? A) Comatose, breathing unlabored B) Glasgow Coma Scale 8, respirations regular C) Appears to be sleeping, vital signs stable D) Glasgow Coma Scale 13, no ventilator required The correct answer is B: Glasgow Coma Scale 8, respirations regular 17) A client enters the emergency department unconscious via ambulance from the client’s workplace. What document should be given priority to guide the direction of care for this client? A) The statement of client rights and the client self-determination act B) Orders written by the health care provider C) A notarized original of advance directives brought in by the partner D) The clinical pathway protocol of the agency and the emergency department The correct answer is C: A notarized original of advance directives brought in by the partner 18) The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? A) An admission at the change of shifts with atrial fibrillation and heart failure - PN B) Client who had a major stroke 6 days ago - PN nursing student C) A child with burns who has packed cells and albumin IV running - charge nurse D) An elderly client who had a myocardial infarction a week ago - UAP The correct answer is A: An admission at the change of shifts with atrial fibrillation and heart failure – PN 19) A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? A) Increased temperature and lethargy B) Restlessness and increased mucus production C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor The correct answer is B: Restlessness and increased mucus production 20) As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." B) "The urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D) "We notice muscle weakness and some unsteadiness." The correct answer is C: "Clothes are becoming tighter across her abdomen." 21) A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? A) Ask the teenager to wait until a parent or legal guardian can be contacted B) Withhold treatment until telephone consent can be obtained from the partner C) Refer the teenager to a community pediatric hospital emergency department D) Proceed with the triage process in the same manner as any adult client The correct answer is D: Proceed with the triage process in the same manner as any adult client 22) A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? A) Converse with the client to determine if the mucous membranes are impaired B) Report hourly outputs of less than 30 ml/hr C) Monitor client's ability for movement in the bed D) Check skin turgor every 4 hours The correct answer is B: Report output of less than 30 ml/hr 23) The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? A) Our child had chickenpox 6 months ago. B) Strep throat went through all the children at the day care last month. C) Both ears were infected over 3 months age. D) Last week both feet had a fungal skin infection. The correct answer is B: Strep throat went through all the children at the day care last month. 24) A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to A) Discuss the feeling of reluctance with an objective peer or supervisor B) Limit contacts with the client to avoid reinforcement of the manipulative behavior C) Confront the client about the negative effects of behaviors on other clients and staff D) Develop a behavior modification plan that will promote more functional behavior The correct answer is A: Discuss the feeling of reluctance with an objective peer or supervisor 25) A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action A) May result in charges of unlawful seclusion and restraint B) Leaves the nurse vulnerable for charges of assault and battery C) Was appropriate in view of the client’s history of violence D) Was necessary to maintain the therapeutic milieu of the unit The correct answer is A: May result in charges of unlawful seclusion and restraint 26) A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety related to pain The correct answer is A: Pain related to ischemia 27) The provisions of the law for the Americans with Disabilities Act require nurse managers to A) Maintain an environment free from associated hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals D) Consider both mental and physical disabilities The correct answer is B: Provide reasonable accommodations for disabled individuals 28) A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance? A) "I have problems with diarrhea." B) "I have difficulty falling asleep." C) "I have diminished sexual function." D) "I often feel jittery." The correct answer is C: "I have diminished sexual function." 29) A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate? A) ”I will keep the cast for the next day uncovered to prevent burning of the skin." B) ”I can apply an ice pack over the area to relieve itching inside the cast." C) ”The cast should be propped on at least 2 pillows when my child is lying down." D) ”I think I remember that standing cannot be done until after 72 hours." The correct answer is D: "I think I remember that standing cannot be done until after 72 hours." 30) Which statement best describes time management strategies applied to the role of a nurse manager? A) Schedule staff efficiently to cover the needs on the managed unit B) Assume a fair share of direct client care as a role model C) Set daily goals with a prioritization of the work D) Delegate tasks to reduce workload associated with direct care and meetings The correct answer is C: Set daily goals with a prioritization of the work 31) The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? A) Lymphedema and nerve palsy B) Hearing loss and ataxia C) Headaches and vomiting D) Abdominal mass and weakness The correct answer is D: Abdominal mass and weakness 32) A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? A) "I will only have to wear this for 6 months." B) "I should inspect my skin daily." C) "The brace will be worn day and night." D) "I can take it off when I shower." The correct answer is A: "I will only have to wear this for 6 months." 33) The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will A) Improve the quality of care B) Decrease staff turnover C) Minimize the amount of overtime payouts D) Improve team morale The correct answer is D: Improve team morale 34) A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) Fever and chills The correct answer is A: Diffuse expiratory wheezing 35) The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's complaints. The nurse manager's next action should be to A) Walk up to the health care provider and quietly state: "Stop this unacceptable behavior." B) Allow the staff nurse to handle this situation without interference C) Notify the of the other administrative persons of a breach of professional conduct D) D) Request an immediate private meeting with the health care provider and staff nurse The correct answer is D: Request an immediate private meeting with the health care provider and staff nurse 36) A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states “I demand to be released now!” The appropriate action is for the nurse to A) You cannot be released because you are still suicidal. B) You can be released only if you sign a no suicide contract. C) Let’s discuss your decision to leave and then we can prepare you for discharge. D) You have a right to sign out as soon as we get an order from the health care provider's discharge order. Th [Show Less]
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2019 HESI EXIT V3
2019 HESI EXIT V3 1. A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit f... [Show More] or the operating room. What would be the most appropriate intervention by the nurse? A) Explain to the client that the dentures must come out as they may get lost or broken in the operating room B) Ask the client if there are second thoughts about having the procedure C) Notify the anesthesia department and the surgeon of the client's refusal D) Ask the client if the preference would be to remove the dentures in the operating room receiving area The correct answer is D: Ask the client if the preference would be to remove the dentures in the operating room receiving area 2. The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which form of evaluation would best measure learning? A) Performance on written tests B) Responses to verbal questions C) Completion of a mailed survey D) Reported behavioral changes The correct answer is D: Reported behavioral changes 3. The nurse is planning care for an 18 month-old child. Which action should be included in the child's care? A) Hold and cuddle the child frequently B) Encourage the child to feed himself finger food C) Allow the child to walk independently on the nursing unit D) Engage the child in games with other children The correct answer is B: Encourage the child to feed himself finger food 4. A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events B) Detaching or dissociating in this way postpones painful feelings C) This conversion or transferring of a mental conflict to a physical symptom can lead to marital conflict D) To isolate the feelings in this way reduces conflict within the client and with others The correct answer is A: Such fantasies can gratify unconscious wishes or prepare for anticipated future events 5. An appropriate goal for a client with anxiety would be to A) Ventilate anxious feelings to the nurse B) Establish contact with reality C) Learn self-help techniques D) Become desensitized to past trauma The correct answer is C: Learn self-help techniques 6. While the nurse is administering medications to a client, the client states "I do not want to take that medicine today." Which of the following responses by the nurse would be best? A) "That's OK, its all right to skip your medication now and then." B) "I will have to call your doctor and report this." C) "Is there a reason why you don't want to take your medicine?" D) "Do you understand the consequences of refusing your prescribed treatment?" The correct answer is C: "Is there a reason why you don't want to take your medicine?" 7. While caring for a client, the nurse notes a pulsating mass in the client's peri umbilical area. Which of the following assessments is appropriate for the nurse to perform? A) Measure the length of the mass B) Auscultate the mass C) Percuss the mass D) Palpate the mass The correct answer is B: Auscultate the mass 8. A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client? A) "Good morning. Do you remember where you are?" B) "Hello. My name is Elaine Jones and I am your nurse for today." C) "How are you today? Remember, you're in the hospital." D) "Good morning. You’re in the hospital. I am your nurse Elaine Jones." The correct answer is D: "Good morning. 9. The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age? A) Formula or breast milk B) Dilute nonfat dry milk C) Warmed fruit juice D) Fluoridated tap water The correct answer is A: Formula or breast milk 10. The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children? A) Growth problems will occur if the fracture involves the periosteum B) Epiphyseal fractures often interrupt a child's normal growth pattern C) Children usually heal very quickly, so growth problems are rare D) Adequate blood supply to the bone prevents growth delay after fractures The correct answer is B: Epiphyseal fractures often interrupt a child''s normal growth pattern 11. The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)? A) April 8 B) January 15 C) February 11 D) December 23 The correct answer is D: December 23 12. When screening children for scoliosis, at what time of development would the nurse expect early signs to appear? A) Prenatally on ultrasound B) In early infancy C) When the child begins to bear weight D) During the preadolescent growth spurt The correct answer is D: During the preadolescent growth spurt 13. A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action? A) Discharge the client from home health care related to noncompliance B) Notify the health care provider of the client's failure to follow prescribed diet C) Discuss diet with the client to learn the reasons for not following the diet D) Make a referral to Meals-on-Wheels The correct answer is C: Discuss diet with client to learn the reasons for not following the diet 14. A client states, "People think I’m no good, you know what I mean?" Which of these responses would be most therapeutic? A) "Well people often take their own feelings of inadequacy out on others." B) "I think you’re good. So you see, there’s one person who likes you." C) "I’m not sure what you mean. Tell me a bit more about that." D) "Let's discuss this to see the reasons to create this impression on people?" The correct answer is C: "I’m not sure what you mean. Tell me a bit more about that." 15. A client being treated for hypertension returns to the community clinic for follow up. The client says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." Which of these is the best nursing diagnosis? A) Noncompliance related to medication side effects B) Knowledge deficit related to misunderstanding of disease state C) Defensive coping related to chronic illness D) Altered health maintenance related to occupation The correct answer is A: Noncompliance related to medication side effects 16. When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend? A) Biofeedback B) Deep breathing C) Distraction D) Imagery The correct answer is B: Deep breathing 17. When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in? A) Competitive board games with older children B) Playing with their own toys along side with other children C) Playing alone with hand held computer games D) Playing cooperatively with other preschoolers The correct answer is D: Playing cooperatively with other preschoolers 18. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding? A) Hold a rattle B) Bang two blocks C) Drink from a cup D) Wave "bye-bye" The correct answer is A: Hold a rattle 19. When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child? A) Provide a verbal explanation just prior to the surgery B) Provide the child with a booklet to read about the surgery C) Introduce the child to another child who had heart surgery 3 days ago D) Explain the surgery using a model of the heart The correct answer is D: Explain the surgery using a model of the heart 20. The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents' comments? A) Focus on the child's needs and recovery B) Explain the cause of the child's illness C) Acknowledge that early care would have been better D) Accept their feelings without judgment The correct answer is D: Accept their feelings without judgment 21. When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse? A) Record the number of stools per day B) Maintain strict intake and output records C) Sterile technique for dressing change at IV site D) Monitor for cardiac arrhythmias The correct answer is C: Sterile technique for dressing change at IV site 22. When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary artery after a myocardial infarction, which finding would be of greatest concern to the nurse? A) Sero sanginous drainage from gums B) Hematemesis C) Pink frothy sputum D) Slight red color at urine The correct answer is B: Hematemesis 23. A 52 year-old client is being transfused with one unit of packed cells. A half hour after the transfusion was initiated, the client complains of chills and headache. Which action should the nurse implement first? A) Notify the health care provider B) Check the client's temperature C) Stop the transfusion D) Obtain a urine specimen The correct answer is C: Stop the transfusion 24. An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding episode. Which order should be questioned by the nurse? A) Passive range of motion B) Replacement of factor VIII C) Aspirin for pain management D) Immobilization splint The correct answer is C: Aspirin for pain management 25. The nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which statement by the mother would indicate the need for further teaching? A) "Nystatin should be given 4 times a day after my baby eats." B) "I will boil the nipples and pacifiers for twenty minutes." C) "I should be taking the medication prescribed for this infection." D) "The therapy can be discontinued when the spots disappear." The correct answer is D: "The therapy can be discontinued when the spots disappear." 26. The nurse is preparing a client for discharge following in-patient treatment for pulmonary tuberculosis. Which of these instructions should be given to the client? A) Continue medication until findings are relieved B) Continue medication use as prescribed C) Avoid contact with children, pregnant women or immune depressed persons D) Take medication with Amphogel if epigastric distress occurs The correct answer is B: Continue medication use as prescribed 27. The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse's immediate attention? A) "I have a burning sensation when I urinate." B) "I have soreness and aching in my muscles." C) "I am itching all over." D) "I have cramping in my stomach." The correct answer is C: "I am itching all over." 28. A woman diagnosed with bipolar disorder is to take lithium (Lithane) as part of the treatment. What should the nurse discuss with the client as part of the teaching plan? A) Risks of oral contraceptives B) Reduction in exercise program C) Avoidance of alcohol D) Cessation of smoking The correct answer is C: Avoidance of alcohol 29. The nurse prepares to administer eye drops to a 6 year-old child. Which of these demonstrates the correct method for instillation of eye drops? A) Directly on the anterior surface of the eyeball B) In the corner where the lids meet C) Under the upper lid as it is pulled upward D) In the conjunctival sac as the lower lid is pulled down The correct answer is D: In the conjunctival sac as the lower lid is pulled down 30. A depressed client is experiencing severe insomnia. The health care provider orders trazadone (Desyrel). The nurse tells the client to expect A) Improvement of acne B) Relief of insomnia C) Reduced arthritic pain D) Less nasal stuffiness The correct answer is B: Relief of insomnia 31. A client with diabetes has a blood sugar is 306 this morning. After the nurse reports this lab result and the client's symptoms of excessive hunger and thirst, what would the nurse expect the health care provider to order? A) Orange juice B) Regular insulin C) NPH Insulin D) Repeat blood sugar level The correct answer is B: Regular insulin 32. The nurse is planning to administer otic drops to a 6 year-old child. Which of the following is the correct procedure? A) Hold the pinna up and back to instill the drops B) Place several drops in the outer ear C) Insert cotton in the outer ear after giving medication D) Assist the child to lie on the affected side afterwards The correct answer is A: Hold the pinna up and back to instill the drops 33. A 1 year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time? A) Use aseptic technique during dressing changes B) Maintain central line catheter integrity C) Monitor serum glucose levels D) Check results of liver function tests The correct answer is C: Monitor serum glucose levels 34. Today's prothrombin time for a client receiving Coumadin is 20 (normal range listed by the lab is 10-14). What is the appropriate nursing action? A) Notify the health care provider immediately B) Recognize that this is a therapeutic level C) Observe the client for hematoma development D) Assess for bleeding at gums or IV sites The correct answer is B: Recognize that this is a therapeutic level 35. The nurse administered intravenous gamma globulin to an 18 month-old child with AIDS. The parent asks why this medication is being given. What is the nurse’s best response? A) "It will slow down the replication of the virus." B) "This medication will improve your child's overall health status." C) "This medication is used to prevent bacterial infections." D) "It will increase the effectiveness of the other medications your child receives." The correct answer is C: "This medication is used to prevent bacterial infections." 36. The nurse is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse's immediate attention? A) Temperature of 37.5 degrees Celsius B) Urine output of 300 cc in 4 hours C) Poor skin turgor D) Blood glucose of 350 mg/dl The correct answer is D: Blood glucose of 350 mg/dl 37. The nurse is teaching a client with asthma about the correct use of the Azmacort (triamcinolone) inhaler. Which of the following statements, if made by the client, would indicate that the teaching was effective? A) "The inhaler can be used whenever I feel short of breath." B) "I should rinse my mouth after using the inhaler." C) "If I forget a dose, I can double up on the next dose." D) I should not use a spacer with my Azmacort. The correct answer is B: "I should rinse my mouth after [Show Less]
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2018 HESI EXIT V4
1. The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child? A) Make certain ... [Show More] the child is maintained in correct body alignment. B) Be sure the traction weights touch the end of the bed. C) Adjust the head and foot of the bed for the child's comfort D) Release the traction for 15-20 minutes every 6 hours PRN. The correct answer is A: Make certain the child is maintained in correct body alignment. 2. The nurse is assessing a healthy child at the 2 year checkup. Which of the following should the nurse report immediately to the health care provider? A) Height and weight percentiles vary widely B) Growth pattern appears to have slowed C) Recumbent and standing height are different D) Short term weight changes are uneven The correct answer is A: Height and weight percentiles vary widely 3. The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse? A) Teach the parents how to perform cardiopulmonary resuscitation B) Recommend that the parents give in when he holds his breath to prevent anoxia C) Advise the parents to ignore breath holding because breathing will begin as a reflex D) Instruct the parents on how to reason with the child about possible harmful effects The correct answer is C: Advise the parents to ignore breath holding because breathing will begin as a reflex 4. The nurse is assessing a client in the emergency room. Which statement suggests that the problem is acute angina? A) "My pain is deep in my chest behind my sternum." B) "When I sit up the pain gets worse." C) "As I take a deep breath the pain gets worse." D) "The pain is right here in my stomach area." The correct answer is A: "My pain is deep in my chest behind my sternum." . 5. The nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions will best assess the function of the client's recent memory? A) "Name the year." "What season is this?" (pause for answer after each question) B) "Subtract 7 from 100 and then subtract 7 from that." (pause for answer) "Now continue to subtract 7 from the new number." C) "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." D) "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?" The correct answer is C: "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen." 6. In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? A) Food B) Warmth C) Security D) Comfort The correct answer is C: Security 7. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? A) "I cannot give this medication as it is written. I have no idea of what you mean." B) "Would you please clarify what you have written so I am sure I am reading it correctly?" C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful." D) "Please print in the future so I do not have to spend extra time attempting to read your writing." The correct answer is B) "Would you please clarify what you have written so I am sure I am reading it correctly?" 8. What is the most important consideration when teaching parents how to reduce risks in the home? A) Age and knowledge level of the parents B) Proximity to emergency services C) Number of children in the home D) Age of children in the home The correct answer is D: Age of children in the home 9. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should A) Administer a placebo B) Encourage increased fluid intake C) Administer the prescribed analgesia D) Recommend relaxation exercises for pain control The correct answer is C: Administer the prescribed analgesia 10. While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention? A) Respiratory rate of 42 B) Lethargy for the past hour C) Apical pulse of 54 D) Coughing up copious secretions The correct answer is A: Respiratory rate of 30 11. A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings? A) Lethargy B) Heat intolerance C) Diarrhea D) Skin eruptions The correct answer is A: Lethargy 12. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? A) "Do not worry. Epilepsy can be treated with medications." B) "The seizure may or may not mean your child has epilepsy." C) "Since this was the first convulsion, it may not happen again." D) "Long term treatment will prevent future seizures." The correct answer is B: "The seizure may or may not mean your child has epilepsy." 13. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies? A) Risk for injury B) Risk for knowledge deficit C) Altered thought process D) Disturbance in self-esteem The correct answer is A: Risk for injury 14. The nurse is caring for a 10 month-old infant who is has oxygen via mask. It is important for the nurse to maintain patency of which of these areas? A) Mouth B) Nasal passages C) Back of throat D) Bronchials The correct answer is B: Nasal passages 15. The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client? A) "Take at least 2 weeks off from work." B) "You will need another chest x-ray in 6 weeks." C) "Take your temperature every day." D) "Complete all of the antibiotic even if your findings decrease." The correct answer is D: "Complete all of the antibiotic even if your findings decrease." 16. When counseling a 6 year old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder? A) Has no clear etiology B) May be associated with sleep phobia C) Has a definite genetic link D) Is a sign of willful misbehavior The correct answer is A: Has no clear etiology 17. The nurse is discussing negativism with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior? A) Reprimand the child and give a 15 minute "time out" B) Maintain a permissive attitude for this behavior C) Use patience and a sense of humor to deal with this behavior D) Assert authority over the child through limit setting The correct answer is C: Use patience and a sense of humor to deal with this behavior 18. The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following demonstrates appropriate teaching by the nurse? A) Chewable aspirin is the preferred analgesic B) Topical cortisone ointment relieves itching C) Papules, vesicles, and crusts will be present at one time D) The illness is only contagious prior to lesion eruption The correct answer is C: Papules, vesicles, and crusts will be present at one time 19. The nurse is assigned to a client who has heart failure . During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first? A) Take the client's vital signs B) Place the client in a sitting position with legs dangling C) Contact the health care provider D) Administer the PRN anti anxiety agent The correct answer is B: Place the client in a sitting position with legs dangling 20. The nurse is caring for a toddler with atopic dermatitis. The nurse should instruct the parents to A) Dress the child warmly to avoid chilling B) Keep the child away from other children for the duration of the rash C) Clean the affected areas with tepid water and detergent D) Wrap the child's hand in mittens or socks to prevent scratching The correct answer is D: Wrap the child''s hand in mittens or socks to prevent scratching 21. A recovering alcoholic asked the nurse, "Will it be ok for me to just drink at special family gatherings?" Which initial response by the nurse would be best? A) "A recovering person has to be very careful not to lose control, therefore, confine your drinking just at family gatherings." B) "At your next AA meeting discuss the possibility of limited drinking with your sponsor." C) "A recovering person needs to get in touch with their feelings. Do you want a drink?" D) "A recovering person cannot return to drinking without starting the addiction process over." The correct answer is D: "The recovering person cannot return to drinking without starting the addiction process over." 22. In taking the history of a pregnant woman, which of the following would the nurse recognize as the primary contraindication for breast feeding? A) Age 40 years B) Lactose intolerance C) Family history of breast cancer D) Uses cocaine on weekends The correct answer is D: Uses cocaine on weekends 23. A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor in relation to this medication? A) Potassium B) Arterial blood gasses C) Blood urea nitrogen D) Thiocyanate The correct answer is D: Thiocyanate 24. A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond? A) With acceptance and views the victim’s comment as an indication that their marriage is in trouble B) With fear of rejection causing increased rage toward the victim C) With a new commitment to seek counseling to assist with their marital problems D) With relief, and welcomes the separation as a means to have some personal time The correct answer is B: With fear of rejection causing increased rage toward the victim 25. A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's initial intervention should be what focus? A) Discuss with the mother sharing parenting responsibilities B) Set time aside to get the mother to express her feelings and concerns C) Arrange for the parents to attend infant care classes D) Talk with the father and help him accept the wife's decision The correct answer is B: Set time aside to get the mother to express her feelings and concerns 26. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client A) Eat foods high in sodium increases sputum liquefaction B) Use oxygen during meals improves gas exchange C) Perform exercise after respiratory therapy enhances appetite D) Cleanse the mouth of dried secretions reduces risk of infection The correct answer is B: Use oxygen during meals improves gas exchange 27. Which of these parents’ comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis? A) I noticed a little lump a little above the belly button. B) The baby seems hungry all the time. C) Mild vomiting that progressed to vomiting shooting across the room. D) Irritation and spitting up immediately after feedings. The correct answer is C: Mild emesis progressing to projectile vomiting 28. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as cause for the findings? A) Decreased cardiac output B) Tissue hypoxia C) Cerebral edema D) Reduced oxygen saturation The correct answer is B: Tissue hypoxia 29. The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet A) High in carbohydrates and proteins B) Low in carbohydrates and proteins C) High in carbohydrates, low in proteins D) Low in carbohydrates, high in proteins The correct answer is A: High in carbohydrates and proteins 30. In evaluating the growth of a 12 month-old child, which of these findings would the nurse expect to be present in the infant? A) Increased 10% in height B) 2 deciduous teeth C) Tripled the birth weight D) Head > chest circumference The correct answer is C: Tripled the birth weight 31. A Hispanic client in the postpartum period refuses the hospital food because it is "cold." The best initial action by the nurse is to A) Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes B) Ask the client what foods are acceptable or bad C) Encourage her to eat for healing and strength D) Schedule the dietitian to meet with the client as soon as possible The correct answer is B: Ask the client what foods are acceptable 32. The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for his age. Which of the following would the nurse expect at this age? A) Cooing B) Imitation of sounds C) Throaty sounds D) Laughter The correct answer is B: Imitation of Sounds 33. The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended? A) Seizures B) Withdrawal C) Craving D) Marked tolerance The correct answer is B: Withdrawal 34. Immediately following an acute battering incident in a violent relationship, the batterer may respond to the partner’s injuries by A) Seeking medical help for the victim's injuries B) Minimizing the episode and underestimating the victim’s injuries C) Contacting a close friend and asking for help D) Being very remorseful and assisting the victim with medical care The correct answer is B: Minimizing the episode and underestimating the victim’s injuries 35. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse? A) "Do you want to take this pretty red medicine?" B) "You will feel better if you take your medicine." C) "This is your medicine, and you must take it all right now." D) "Would you like to take your medicine from a spoon or a cup?" The correct answer is D: "Would you like to take your medicine from a spoon or a cup?" 36. In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and [Show Less]
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2019 HESI EXIT V5
1. The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis? A) Nutrition ... [Show More] B) Elimination C) Activity D) Safety The correct answer is D: Safety 2. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age? A) They are able to make simple association of ideas B) They are able to think logically in organizing facts C) Interpretation of events originate from their own perspective D) Conclusions are based on previous experiences The correct answer is B: Think logically in organizing facts 3. The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse do first? A) Clear the area of any hazards B) Place the child on the side C) Restrain the child D) Give the prescribed anticonvulsant The correct answer is B: Place the child on the side 4. The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to A) Reports of difficulty falling and staying asleep B) Expression of persistent suicidal thoughts C) Lack of enjoyment in usual pleasures D) Reduced senses of taste and smell The correct answer is C: Lack of enjoyment in usual pleasures 5. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to A) Administer pain medication B) Suction excessive tracheobronchial secretions C) Assist client to turn, deep breathe and cough D) Monitor oxygen saturation The correct answer is B: Suction excessive tracheobronchial secretions 6. While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client? A) Compulsive behavior B) Sense of impending doom C) Fear of flying D) Predictable episodes The correct answer is B: Sense of impending doom 7. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse? A) Arrange to change client care assignments B) Explain that this behavior is expected C) Discuss the appropriate use of "time-out" D) Explain that the child needs extra attention The correct answer is B: Explain that this behavior is expected 8. A 15 year-old client with a lengthy confining illness is at risk for altered growth and development of which task? A) Loss of control B) Insecurity C) Dependence D) Lack of trust The correct answer is C: Dependence 9. Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children? A) Sports and games with rules B) Finger paints and water play C) "Dress-up" clothes and props D) Chess and television programs The correct answer is A: Sports and games with rules 10. The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is A) "Eat a balanced diet for your age." B) "Increase your intake of protein and Vitamin A." C) "Decrease fatty foods from your diet." D) "Do not use caffeine in any form, including chocolate." The correct answer is A: "Eat a balanced diet for your age." 11. The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds A) "The complaints of at least 3 common findings." B) "The absence of any opportunistic infection." C) "CD4 lymphocyte count is less than 200." D) "Developmental delays in children." The correct answer is C: "CD4 lymphocyte count is less than 200." 12. The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate? A) Offer ice cream every 2 hours B) Place the child in a supine position C) Allow the child to drink through a straw D) Observe swallowing patterns The correct answer is D: Observe swallowing patterns 13. A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? A) Acceptance of the pregnancy B) Focus on fetal development C) Anticipation of the birth D) Ambivalence about pregnancy The correct answer is C: Anticipation of the birth 14. The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions? A) Administration of cough suppressants B) Increasing oral fluid intake to 3000 cc per day C) Maintaining bed rest with bathroom privileges D) Performing chest physiotherapy twice a day The correct answer is B: Increasing oral fluid intake to 3000 cc per day 15. The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up? A) A 13 month-old unable to walk B) A 20 month-old only using 2 and 3 word sentences C) A 24 month-old who cries during examination D) A 30 month-old only drinking from a sip cup The correct answer is D: A 30 month-old only drinking from a sip cup 16. Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes? A) Give written pre and post tests B) Ask questions during practice C) Allow another diabetic to assist D) Observe a return demonstration The correct answer is D: Observe a return demonstration 17. A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority? A) Elevate leg on 2 pillows B) Apply support stockings C) Apply warm compresses D) Maintain complete bed rest The correct answer is A: Elevate leg on 2 pillows 18. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child? A) Congenital cardiac defects B) An acute febrile illness C) Prolonged hypoxemia D) Severe multiple trauma The correct answer is C: Prolonged hypoxemia 19. A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to A) A social worker from the local hospital B) An occupational therapist from the community center C) A physical therapist from the rehabilitation agency D) Another client with diabetes mellitus and takes insulin The correct answer is B: An occupational therapist from the community center 20. A priority goal of involuntary hospitalization of the severely mentally ill client is A) Re-orientation to reality B) Elimination of symptoms C) Protection from harm to self or others The correct answer is C: Protection from self harm and harm to others 21. The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend A) Isometric B) Range of motion C) Aerobic D) Isotonic The correct answer is A: Isometric 22. The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report A) Loss of consciousness B) Feeding problems C) Poor weight gain D) Fatigue with crying The correct answer is A: Loss of consciousness 23. A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would A) Instruct the client to maintain a regular diet the day prior to the examination B) Restrict the client's fluid intake 4 hours prior to the examination C) Administer a laxative to the client the evening before the examination D) Inform the client that only 1 x-ray of his abdomen is necessary The correct answer is C: Administer a laxative to the client the evening before the examination 24. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? A) Altered tissue perfusion B) Risk for fluid volume deficit C) High risk for hemorrhage D) Risk for infection The correct answer is D: Risk for infection 25. The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that A) Circumcision is delayed so the foreskin can be used for the surgical repair B) This procedure is contraindicated because of the permanent defect C) There is no medical indication for performing a circumcision on any child D) The procedure should be performed as soon as the infant is stable The correct answer is A: Circumcision is delayed so the foreskin can be used for the surgical repair 26. The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect? A) Confusion B) Loss of half of visual field C) Shallow respirations D) Tonic-clonic seizures The correct answer is C: Shallow respirations 27. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings? A) These side effects are common and should subside in a few days B) The client is probably having an allergic reaction and should discontinue the drug C) Taking the lithium on an empty stomach should decrease these symptoms D) Decreasing dietary intake of sodium and fluids should minimize the side effects The correct answer is A: These side effects are common and should subside in a few days 28. A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse? A) Ask the client if he has noticed any bleeding or dark stools B) Tell the client to call 911 and go to the emergency department immediately C) Schedule a repeat Hemoglobin and Hematocrit in 1 month D) Tell the client to schedule an appointment with a hematologist The correct answer is A: Ask the client if he has noticed any bleeding or dark stools 29. A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the A) Surgical repair of a diseased coronary artery B) Placement of an automatic internal cardiac defibrillator C) Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow D) Non-invasive radiographic examination of the heart The correct answer is C: Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow 30. For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate? A) Institute seizure precautions B) Weigh the child twice per shift C) Encourage the child to eat protein-rich foods D) Relieve boredom through physical activity The correct answer is A: Institute seizure precautions 31. Following mitral valve replacement surgery a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 micro drops/cc. What rate would deliver 4 mgm of Lidocaine/ minute? A) 60 microdrops/minute B) 20 microdrops/minute C) 30 microdrops/minute D) 40 microdrops/minute The correct answer is A: 60 microdrops/minute 2 gm=2000 mgm 2000 mgm/500 cc = 4 mgm/x cc 2000x = 2000 x= 2000/2000 = 1 cc of IV solution/minute CC x 60 microdrops = 60 microdrops/minute 32. An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first? A) Review the client's weight pattern over the year B) Ask the mother to record her diet for the last 24 hours C) Encourage her to talk about her view of herself D) Give her several pamphlets on postpartum nutrition The correct answer is C: Encourage her to talk about her view of herself 33. To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would A) Assist the client to use the bedside commode B) Administer stool softeners every day as ordered C) Administer anti dysrhythmics prn as ordered D) Maintain the client on strict bed rest The correct answer is B: Administer stool softeners every day as ordered 34. A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should A) Expose the cast to air and turn the child frequently B) Use a heat lamp to reduce the drying time C) Handle the cast with the abductor bar D) Turn the child as little as possible The correct answer is A: Expose the cast to air and turn the child frequently 35. The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate postoperative period? A) Raise the head of the bed at least 30 degrees B) Encourage ambulation within 24 hours C) Maintain in a flat position, logrolling as needed D) Encourage leg contraction and relaxation after 48 hours The correct answer is C: Maintain in a flat position, logrolling as needed 36. A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to A) Convince the client that the hospital staff is trying to help B) Help the client to enter into group recreational activities C) Provide interactions to help the client learn to trust staff D) Arrange the environment to limit the client’s contact with other clients The correct answer is C: Provide interactions to help the client learn to trust staff 37. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate? A) Unequal leg length B) Limited adduction C) Diminished femoral pulses D) Symmetrical gluteal folds The correct answer is A: Unequal leg length 38. A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has su [Show Less]
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2020 HESI EXIT V6
1. A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which ... [Show More] statement most accurately describes thoughts on death and dying at this age? A) Death is personified as the bogeyman or devil B) Death is perceived as being irreversible C) The child feels guilty for the grandmother's death D) The child is worried that he, too, might die The correct answer is A: Death is personified as the bogeyman or devil 2. A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present A) Temperature of 37.5 degrees Celsius with painful urination B) An open wound on their heel C) Insomnia and daytime fatigue D) Nausea with 2 episodes of vomiting The correct answer is B: An open wound on their heel 3. The nurse admits an elderly Mexican-American migrant worker after an accident that occurred during work. To facilitate communication the nurse should initially A) Request a Spanish interpreter B) Speak through the family or co-workers C) Use pictures, letter boards, or monitoring D) Assess the client's ability to speak English The correct answer is D: Assess the client’s ability to speak English 4. In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings? A) Uterine atony B) Genital lacerations C) Retained placenta D) Clotting disorder The correct answer is B: Genital lacerations 5. The nurse notes an abrupt onset of confusion in an elderly patient. Which of the following recently-ordered medications would most likely contribute to this change? A) Anticoagulant B) Liquid antacid C) Antihistamine D) Cardiac glycoside The correct answer is C: Antihistamine 6. The nurse is caring for a client with active tuberculosis who has a history of noncompliance. Which of the following actions by the nurse would represent appropriate care for this client? A) Instruct the client to wear a high efficiency particulate air mask in public places. B) Ask a family member to supervise daily compliance C) Schedule weekly clinic visits for the client D) Ask the health care provider to change the regimen to fewer medications The correct answer is B: Ask a family member to supervise daily compliance 7. The nurse manager identifies that time spent by staff in charting is excessive, requiring overtime for completion. The nurse manager states that "staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting." The nurse manager's leadership style is best described as A) Laissez-faire B) Autocratic C) Participative D) Group The correct answer is C: Participative 8. A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate response by the nurse manager should include A) The escalation of fees with a decreased reimbursement percentage B) High costs of diagnostic and end-of-life treatment procedures C) Increased numbers of elderly and of the chronically ill of all ages D) A steep rise in health care provider fees and in insurance premiums The correct answer is A: The escalation of fees with a decreased reimbursement percentage 9. A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in the plan of care within the initial 24 hours for this client? A) Wear masks with shields if potential splash B) Use disposable utensils and plates for meals C) Wear gown and gloves during client contact D) Provide soft easily digested food with frequent snacks The correct answer is C: Wear gown and gloves during client contact 10. A client has been taking alprazolam (Xanax) for 3 days. Nursing assessment should reveal which expected effect of the drug? A) Tranquilization, numbing of emotions B) Sedation, analgesia C) Relief of insomnia and phobias D) Diminished tachycardia and tremors associated with anxiety The correct answer is A: Tranquilization, numbing of emotions 11. The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is A) Advising client to restrict sodium intake B) Taking the blood pressure in the left arm C) Elevating her left arm above heart level D) Compressing the drainage device The correct answer is B: Taking the blood pressure in the left arm 12. A 70 year-old post-operative client has elevated serum BUN, Hct, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is: A) Impaired gas exchange B) Metabolic acidosis C) Renal insufficiency D) Fluid volume deficit The correct answer is D: Fluid volume deficit 13. The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated A) "I can only wear cotton socks." B) "I cannot go barefoot around my house." C) "I will trim corns and calluses regularly." D) "I should ask a family member to inspect my feet daily." The correct answer is C: "I will trim corns and calluses regularly." 14. A woman who delivered 5 days ago and had been diagnosed with preeclampsia calls the hospital triage nurse hotline to ask for advice. She states “ I have had the worst headache for the past 2 days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps.” What should the nurse do next? A) Advise the client that the swings in her hormones may have that effect. However, suggest for her to call her health care provider within the next day. B) Advise the client to have someone bring her to the emergency room as soon as possible C) Ask the client to stay on the line, get the address and send an ambulance to the home D) Ask what the client has taken? How often? Ask about other specific complaints. The correct answer is C: Ask the client to stay on the line, get the address and send an ambulance to the home 15. The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is A) Drink 3000 to 4000 cc of fluid each day for one month B) Limit fluid intake to 1000 cc each day for one month C) Increase intake of citrus fruits to three servings per day D) Restrict milk and dairy products for one month The correct answer is A: Drink 3000 to 4000 cc of fluid each day for 1 month 16. A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the nurse? A) Avoid Alka-Seltzer because it contains aspirin B) Take Alka-Seltzer at a different time of day than the warfarin C) Select another antacid that does not inactivate warfarin D) Use on-half the recommended dose of Alka-Seltzer The correct answer is A: Avoid Alka-Seltzer because it contains aspirin 17. The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A priority nursing intervention would be to A) Encourage the parents to enroll in cardiopulmonary resuscitation class B) Assist the parents to plan quiet play activities at home C) Stress to the parents that they will need relief care givers D) Instruct the parents to avoid contact with persons with infection The correct answer is A: Encourage the parents to enroll in cardiopulmonary resuscitation class 18. The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive priority in the plan of care? A) Risk for injury B) Self care deficit C) Alteration in comfort D) Alteration in mobility The correct answer is C: Alteration in comfort 19. An unlicensed assistive staff member asks the nurse manager to explain the beliefs of a Christian Scientist who refuses admission to the hospital after a motor vehicle accident. The best response of the nurse would be which of these statements? A) "Spiritual healing is emphasized and the mind contributes to the cure." B) "The primary belief is that dietary practices result in health or illness." C) "Fasting and prayer are initial actions to take in physical injury." D) "Meditation is intensive in the initial 48 hours and daily thereafter." The correct answer is A: "Spiritual healing is emphasized and the mind contributes to the cure." 20. In order to be effective in administering cardiopulmonary resuscitation to a 5 year- old, the nurse must A) Assess the brachial pulses B) Breathe once every 5 compressions C) Use both hands to apply chest pressure D) Compress 80-90 times per minute The correct answer is B: Breathe once every 5 compressions 21. The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care? A) Impaired skin integrity related to dependent edema B) Activity intolerance related to oxygen supply and demand imbalance C) Constipation related to immobility D) Risk for infection related to ineffective mobilization of secretions The correct answer is B: Activity Intolerance related to oxygen supply and demand imbalance 22. For which of the following mother-baby pairs should the nurse review the Coomb's test in preparation for administering RhO (D) immune globulin within 72 hours of birth? A) Rh negative mother with Rh positive baby B) Rh negative mother with Rh negative baby C) Rh positive mother with Rh positive baby D) Rh positive mother with Rh negative baby The correct answer is A: Rh negative mother with Rh positive baby 23. An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first? A) Lung sounds B) Urine output C) Level of alertness D) Appetite The correct answer is C: Level of alertness 25. What is the major purpose of community health research? A) Describe the health conditions of populations B) Evaluate illness in the community C) Explain the health conditions of families D) Identify the health conditions of the environment The correct answer is A: Describe the health conditions of populations 26. The recent increase in the reported cases of active tuberculosis (TB) in the United States is attributed to which factor? A) The increased homeless population in major cities B) The rise in reported cases of positive HIV infections C) The migration patterns of people from foreign countries D) The aging of the population located in group homes The correct answer is B: The rise in reported cases of positive HIV infections 27. A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki Disease. The nurse recognizes that which of the following scheduled immunizations will be delayed? A) MMR B) Hib C) IPV D) DtaP The correct answer is A: MMR 28. The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor? A) Sexually transmitted infection B) Exposure to teratogens C) Maternal hypertension D) Chromosomal abnormalities The correct answer is C: Maternal hypertension 29. After the shift report in a labor and delivery unit which of these clients would the nurse check first? A) A middle aged woman with asthma and diabetes mellitus Type 1 has a BP of 150/94 B) A middle aged woman with a history of two prior vaginal term births is 2 cm dilated C) A young woman is a grand multipara has cervical dilation of 4 cm and 50% effaced D) An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum The correct answer is D: An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum 30. The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately? A) Fecal impaction B) Infrequent voiding C) Stress incontinence D) Burning with urination The correct answer is A: Fecal impaction 31. The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse should A) Irrigate it as ordered with distilled water B) Irrigate it as ordered with normal saline C) Place the end of the tube in water to see if the water bubbles D) Withdraw the tube several inches and reposition it The correct answer is B: Irrigate it as ordered with normal saline 32. The parents of a child who has recently been diagnosed with asthma ask the nurse to explain the condition to them. The best response is "Asthma causes… A) the airway to become narrow and obstructs airflow." B) air to be trapped in the lungs because the airways are dilated." C) the nerves that control respiration to become hyperactive." D) a decrease in the stress hormones which prevents the airways from opening." The correct answer is A: the airway to become narrow and obstructs airflow." 33. The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find? A) Complaints of numbness and tingling in feet B) Wheezing noted when lung sound auscultated C) Excessive perspiration D) Difficulty sleeping The correct answer is A: Complaints of numbness and tingling in feet 34. The nurse is caring for a client with end-stage heart failure. The family members are distressed about the client's impending death. What action should the nurse do first? A) Explain the stages of death and dying to the family B) Recommend an easy-to-read book on grief C) Assess the family's patterns for dealing with death D) Ask about their religious affiliations The correct answer is C: Assess the family''s patterns for dealing with death 35. The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in A) Calcium B) Fiber C) Sodium D) Carbohydrate The correct answer is C: Sodium 36. The nurse is teaching a mother who will breast feed for the first time. Which of the following is a priority? A) Show her films on the physiology of lactation B) Give the client several illustrated pamphlets C) Assist her to position the newborn at the breast D) Give her privacy for the initial feeding The correct answer is C: Assist her to position the newborn at the breast 37. The nurse is taking a health history from parents of a child admitted with possible Reye's Syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye's Syndrome? A) Rubeola B) Meningitis C) Varicella D) Hepatitis The correct answer is C: Varicella 38. While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of what psychosocial skill? A) Stubborn behavior B) Rejection of parents C) Frustration with adults D) Assertion of control The correct answer is D: Assertion of control 39. A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn assessments suggests to the nurse that the infant has fetal alcohol syndrome? A) Growth retardation is evident B) Multiple anomalies are identified C) Cranial facial abnormalities are noted D) Prune belly syndrome is suspected The correct answer is C: Cranial facial abnormalities are noted 40. The nurse is attending a workshop about caring for persons infected with Hepatitis. Which statement is correct when referring to the incidence rate for Hepatitis? A) The number of persons in a population who develop Hepatitis B during a specific period of time B) The total number of persons in a population who have Hepatitis B at a particular time C) The percentage of deaths resulting from Hepatitis B during a specific time D) The occurrence of Hepatitis B in the population at a particular time The correct answer is A: The number of persons in a population who develop Hepatitis B during a specific period of time 41. A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client? A) Capillary refill less than 3 seconds B) Pale mucous membranes C) Respirations 36 breaths per minute D) Complaints of fatigue when ambulating The correct answer is A: Capillary refill less than 3 seconds 42. The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB? The nurse is caring for a cli [Show Less]
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