HESI 102 HESI Comprehensive Exit Exam 132 Questions and Answers Spring 2022- Chamberlain College
HESI COMPREHENSIVE
EXIT EXAM
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1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which
assessment does the nurse perform as a priority before administering the
medication?
A. Checking the client's blood pressure
B. Checking the client's peripheral pulses
C. Checking the most recent potassium level
D. Checking the client's intake-and-output record for the last 24 hours
(ANS- A. Checking the client's blood pressure
Checking the client's blood pressure
Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to
treat hypertension. One common side effect is postural hypotension. Therefore the
nurse would check the client's blood pressure immediately before administering
each dose. Checking the client's peripheral pulses, the results of the most recent
potassium level, and the intake and output for the previous 24 hours are not
specifically associated with this mediation.
2-A client is scheduled to undergo an upper gastrointestinal (GI) series, and the
nurse provides instructions to the client about the test. Which statement by the
client indicates a need for further instruction?
A. "The test will take about 30 minutes."
B. "I need to fast for 8 hours before the test."
C. "I need to drink citrate of magnesia the night before the test and give myself a
Fleet enema on the morning of the test."
D. "I need to take a laxative after the test is completed, because the liquid that I'll
have to drink for the test can be constipating."
(ANS- C. "I need to drink citrate of magnesia the night before the test and give
myself a Fleet enema on the morning of the test."
An upper GI series involves visualization of the esophagus, duodenum, and upper
jejunum by means of the use of a contrast medium. It involves swallowing a
contrast medium (usually barium), which is administered in a flavored milkshake.
Films are taken at intervals during the test, which takes about 30 minutes. No
special preparation is necessary before a GI series, except that NPO status must be
maintained for 8 hours before the test. After an upper GI series, the client is
prescribed a laxative to hasten elimination of the barium. Barium that remains in
the colon may become hard and difficult to expel, leading to fecal impaction.
3-A nurse on the evening shift checks a physician's prescriptions and notes that the
dose of a prescribed medication is higher than the normal dose. The nurse calls the
physician's answering service and is told that the physician is off for the night and
will be available in the morning. The nurse should:
A. Call the nursing supervisor
B. Ask the answering service to contact the on-call physician
C. Withhold the medication until the physician can be reached in the morning
D. Administer the medication but consult the physician when he becomes available
(ANS- B. Ask the answering service to contact the on-call physician
4.An emergency department (ED) nurse is monitoring a client with suspected acute
myocardial infarction (MI) who is awaiting transfer to the coronary intensive care
unit. The nurse notes the sudden onset of premature ventricular contractions
(PVCs) on the monitor, checks the client's carotid pulse, and determines that the
PVCs are not resulting in perfusion. The appropriate action by the nurse is:
A. Documenting the findings
B. Asking the ED physician to check the client
C. Continuing to monitor the client's cardiac status
D. Informing the client that PVCs are expected after an MI
(ANS- B. Asking the ED physician to check the client
5.NPO status is imposed 8 hours before the procedure on a client scheduled to
undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the
procedure, the nurse checks the client's record and notes that the client routinely
takes an oral antihypertensive medication each morning. The nurse should:
A. Administer the antihypertensive with a small sip of water
B. Withhold the antihypertensive and administer it at bedtime
C. Administer the medication by way of the intravenous (IV) route
D. Hold the antihypertensive and resume its administration on the day after the
ECT
(ANS- A. Administer the antihypertensive with a small sip of water
6 A client who recently underwent coronary artery bypass graft surgery comes to
the physician's office for a follow-up visit. On assessment, the client tells the nurse
that he is feeling depressed. Which response by the nurse is therapeutic?
A. "Tell me more about what you're feeling."
B. "That's a normal response after this type of surgery."
C. "It will take time, but, I promise you, you will get over this depression."
D. "Every client who has this surgery feels the same way for about a month."
(ANS- A. "Tell me more about what you're feeling."
7 A client in labor experiences spontaneous rupture of the membranes. The nurse
immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the
amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor.
Which of the following actions should be the nurse's priority?
A. Contacting the physician
B. Documenting the findings
C. Checking the fluid for protein
D. Continuing to monitor the client and the FHR
(ANS- A. Contacting the physician Correct
8 A nurse has assisted a physician in inserting a central venous access device into a
client with a diagnosis of severe malnutrition who will be receiving parenteral
nutrition (PN). After insertion of the catheter, the nurse immediately plans to:
A. Call the radiography department to obtain a chest x-ray
B. Check the client's blood glucose level to serve as a baseline measurement
C. Hang the prescribed bag of PN and start the infusion at the prescribed rate D.
Infuse normal saline solution through the catheter at a rate of 100 mL/hr to
maintain patency
(ANS- A. Call the radiography department to obtain a chest x-ray
9 A rape victim being treated in the emergency department says to the nurse, "I'm
really worried that I've got HIV now." What is the appropriate response by the
nurse?
A. "HIV is rarely an issue in rape victims."
B. "Every rape victim is concerned about HIV."
C. "You're more likely to get pregnant than to contract HIV."
D. "Let's talk about the information that you need to determine your risk of
contracting HIV."
(ANS- D. "Let's talk about the information that you need to determine your risk of
contracting HIV."
10 A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily,
to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse
that the medication is causing nausea and indigestion. The nurse should tell the
client to:
A. Contact the physician
B. Stop taking the medication
C. Take the medication with food
D. Take the medication twice a day instead of four times
(ANS- C. Take the medication with food
11 A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the
day shift, and 650 mL on the evening shift. The client is receiving an intravenous
(IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The
nurse empties 700 mL of urine from the client's Foley catheter at the end of the day
shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325
mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the
24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL.
What is the client's total intake during the 24-hour period? Type your answer in the
space provided.
Answer: ________mL
(ANS- "1670"
12 Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is
prescribed for a client for the management of anxiety. The nurse prepares the
medication as prescribed and administers the medication over a period of:
A. 3 minutes
B. 10 seconds
C. 15 seconds
D. 30 minutes
(ANS- A. 3
minutes
13 A nurse, conducting an assessment of a client being seen in the clinic for
symptoms of a sinus infection, asks the client about medications that he is taking.
The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On
the basis of this information, the nurse determines that the client most likely has a
history of:
A. Depression
B. Diabetes mellitus
C. Hyperthyroidism
D. Coronary artery disease
(ANS- A. Depression
14 Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse
provides information to the client about the adverse effects of the medication and
tells the client to contact the physician immediately if she experiences:
A. Dry mouth
B. Restlessness
C. Feelings of depression
D. Neck stiffness or soreness
(ANS- D. Neck stiffness or soreness
15 Risperidone (Risperdal) is prescribed for a client hospitalized in the mental
health unit for the treatment of a psychotic disorder. Which finding in the client's
medical record would prompt the nurse to contact the prescribing physician before
administering the medication?
A. The client has a history of cataracts.
B. The client has a history of hypothyroidism.
C. The client takes a prescribed antihypertensive.
D. The client is allergic to acetylsalicylic acid (aspirin).
(ANS- C. The client takes a prescribed antihypertensive.
16 A client who has been undergoing long-term therapy with an antipsychotic
medication is admitted to the inpatient mental health unit. Which of the following
findings does the nurse, knowing that long-term use of an antipsychotic medication
can cause tardive dyskinesia, monitor in the client?
A. Fever
B. Diarrhea
C. Hypertension
D. Tongue protrusion
(ANS- D. Tongue protrusion
17 A nurse is reviewing the record of a client scheduled for electroconvulsive
therapy (ECT). Which of the following diagnoses, if noted on the client's record,
would indicate a need to contact the physician who is scheduled to perform the
ECT?
A. Recent stroke
B. Hypothyroidism
C. History of glaucoma
D. Peripheral vascular disease
(ANS- A. Recent stroke
18 A client scheduled for suprapubic prostatectomy has listened to the surgeon's
explanation of the surgery. The client later asks the nurse to explain again how the
prostate is going to be removed. The nurse tells the client that the prostate will be
removed through:
A. A lower abdominal incision
B. An upper abdominal incision
C. An incision made in the perineal area
D. The urethra, with the use of a cutting wire
(ANS- A. A lower abdominal incision
19 A nurse is preparing a poster for a health fair booth promoting primary
prevention of skin cancer. Which of the following recommendations does the nurse
include on the poster? Select all that apply.
A. Seek medical advice if you find a skin lesion.
B. Use sunscreen with a low sun protection factor (SPF).
C. Avoid sun exposure before 10 a.m. and after 4 p.m.
D. Wear a hat, opaque clothing, and sunglasses when out in the sun.
E. Examine the body every 6 months for possibly cancerous or precancerous
lesions.
(ANS-
A. Seek medical advice if you find a skin lesion.
D. Wear a hat, opaque clothing, and sunglasses when out in the sun.
20 A nurse reviewing the medical record of a client with a diagnosis of infiltrating
ductal carcinoma of the breast notes documentation of the presence of peau
d'orange skin. On the basis of this notation, which finding would the nurse expect
to note on assessment of the client's breast?
(ANSAnatomy with the appearance and dimpled texture of an orange peel
21 The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her
child is a member of the school soccer team and expresses concern about her
child's participation in sports. The nurse, after providing information to the mother
about diet, exercise, insulin, and blood glucose control, tells the mother:
A. To always administer less insulin on the days of soccer games
B. That it is best not to encourage the child to participate in sports activities
C. That the child should eat a carbohydrate snack about a half-hour before each
soccer game
D. To administer additional insulin before a soccer game if the blood glucose level
is 240 mg/dL or higher and ketones are present
(ANS- C. That the child should eat a carbohydrate snack about a half-hour before
each soccer game
22 A client with chronic renal failure who will require dialysis three times a week
for the rest of his life says to the nurse, "Why should I even bother to watch what I
eat and drink? It doesn't really matter what I do if I'm never going to get better!"
On the basis of the client's statement, the nurse determines that the client is
experiencing which problem?
A. Anxiety
B. Powerlessness
C. Ineffective coping
D. Disturbed body image
(ANS- B. Powerlessness
23 A nurse is providing morning care to a client in end-stage renal failure. The
client is reluctant to talk and shows little interest in participating in hygiene care.
Which statement by the nurse would be therapeutic?
A. "What are your feelings right now?"
B. "Why don't you feel like washing up?"
C. "You aren't talking today. Cat got your tongue?"
D. "You need to get yourself cleaned up. You have company coming today." (ANSA. "What are your feelings right now?"
24 Empyema develops in a client with an infected pleural effusion, and the nurse
prepares the client for thoracentesis. What characteristics of the fluid removed
during thoracentesis should the nurse, assisting the physician with the procedure,
expect to note? A. Clear and yellow
B. Thick and opaque
C. White and odorless
D. Clear, with a foul odor
(ANS- B. Thick and opaque
25 An emergency department nurse is told that a client with carbon monoxide
poisoning resulting from a suicide attempt is being brought to the hospital by
emergency medical services. Which intervention will the nurse carry out as a
priority upon arrival of the client?
A. Administering 100% oxygen
B. Having a crisis counselor available
C. Instituting suicide precautions for the client
D. Obtaining blood for determination of the client's carboxyhemoglobin level
(ANS- A. Administering 100% oxygen
26 A nurse is caring for a client with sarcoidosis. The client is upset because he has
missed work and worried about how he will care financially for his wife and three
small children. On the basis of the client's concern, which problem does the nurse
identify?
A. Anxiety
B. Powerlessness
C. Disruption of thought processes
D. Inability to maintain health
(ANS- A. Anxiety
27 A nurse, performing an assessment of a client who has been admitted to the
hospital with suspected silicosis, is gathering both subjective and objective data.
Which question by the nurse would elicit data specific to the cause of this
disorder?
A. "Do you chew tobacco?"
B. "Do you smoke cigarettes?"
C. "Have you ever worked in a mine?"
D. "Are you frequently exposed to paint products?"
(ANS- C. "Have you ever worked in a mine?"
28 A physician prescribes a dose of morphine sulfate 2.5 mg stat to be administered
intravenously to a client in pain. The nurse preparing the medication notes that the
label on the vial of morphine sulfate solution for injection reads "4 mg/mL." How
many milliliters (mL) must the nurse draw into a syringe for administration to the
client? Type the answer in the space provided.
Answer: _____mL
(ANS- 0.625
29 A client undergoing therapy with carbidopa/levodopa (Sinemet) calls the nurse at
the clinic and reports that his urine has become darker since he started taking the
medication. The nurse should tell the client:
A. To call his physician
B. That he needs to drink more fluids
C. That this is an occasional side effect of the medication
D. That this may be a sign of developing toxicity of the medication
(ANS- C. That this is an occasional side effect of the medication Correct
30 A client with myasthenia gravis is taking neostigmine bromide (Prostigmin).
The nurse determines that the client is gaining a therapeutic effect from the
medication after noting:
A. Bradycardia
B. Increased heart rate
C. Decreased blood pressure
D. Improved swallowing function
(ANS- D. Improved swallowing function
31 A nurse is assessing a client who has been taking amantadine hydrochloride
(Symmetrel) for the treatment of Parkinson's disease. Which finding from the
history and physical examination would cause the nurse to determine that the client
may be experiencing an adverse effect of the medication?
A. Insomnia
B. Rigidity and akinesia
C. Bilateral lung wheezes
D. Orthostatic hypotension
(ANS- C. Bilateral lung wheezes
32 A nurse who will be staffing a booth at a health fair is preparing pamphlets
containing information regarding the risk factors for osteoporosis. Which of the
following risk factors does the nurse include in the pamphlet?Select all that apply.
A. Smoking Correct
B. A high-calcium diet
C. High alcohol intake Correct
D. White or Asian ethnicity Correct
E. Participation in physical activities that promote flexibility and muscle strength
(ANS-
A. Smoking Correct
C. High alcohol intake Correct
D. White or Asian ethnicity Correct
33 A nurse is providing instruction to a client with osteoporosis regarding
appropriate foods to include in the diet. The nurse tells the client that one food item
high in calcium is:
A. Corn
B. Cocoa
C. Peaches
D. Sardines
(ANS- D. Sardines
34 A nurse is providing information to a client with acute gout about home care.
Which of the following measures does the nurse tell the client to take? Select all
that apply.
A. Drinking 2 to 3 L of fluid each day
B. Applying heat packs to the affected joint
C. Resting and immobilizing the affected area
D. Consuming foods high in purines
E. Performing range-of-motion exercise to the affected joint three times a day
(ANSA. Drinking 2 to 3 L of fluid each day Correct
C. Resting and immobilizing the affected area Correct
35 A nurse is gathering subjective and objective data from a client with suspected
rheumatoid arthritis (RA). Which early manifestations of RA would the nurse
expect to note? Select all that apply.
A. Fatigue
B. Anemia
C. Weight loss
D. Low-grade fever
E. Joint deformities
(ANSA. Fatigue Correct
D. Low-grade fever Correct
36 A nurse is reviewing the medical record of a client with a suspected systemic
lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect
to find noted in the client's medical record? Select all that apply.
A. Fever
B. Vasculitis
C. Weight gain
D. Increased energy
E. Abdominal pain
(ANS- A.
Fever
B. Vasculitis
E. Abdominal pain
37 A nurse is providing dietary instructions to a client who is taking
tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell
the client to avoid while she is taking this medication? Select all that apply.
A. Beer
B. Apples
C. Yogurt
D. Baked haddock
E. Pickled herring
F. Roasted fresh potatoes (ANS- A. Beer Correct
C. Yogurt Correct
E. Pickled herring Correct
38 The blood serum level of imipramine is determined in a client who is being
treated for depression with Tofranil-PM. The laboratory test indicates a
concentration of 250 ng/mL. On the basis of this result, the nurse should:
A. Contact the physician
B. Hold the next dose of imipramine
C. Document the laboratory result in the client's record
D. Have another blood sample drawn and ask the laboratory to recheck the
imipramine level (ANS- C. Document the laboratory result in the client's record
Correct
39 A nurse provides instructions to a client who has been prescribed lithium
carbonate (Lithobid) for the treatment of bipolar disorder. Which of these
statements by the client indicate a need for further instruction? Select all that apply.
A. "I need to avoid salt in my diet."
B. "It's fine to take any over-the-counter medication with the lithium."
C. "I need to come back the clinic to have my lithium blood level checked."
D. " I should drink 2 to 3 quarts of liquid every day."
E. "Diarrhea and muscle weakness are to be expected, and if these occur I don't
need to be concerned."
(ANS- A. "I need to avoid salt in my diet." Correct
B. "It's fine to take any over-the-counter medication with the lithium." Correct E.
"Diarrhea and muscle weakness are to be expected, and if these occur I don't
need to be concerned." Correct
40 A client who is taking lithium carbonate (Lithobid) complains of mild nausea,
voiding in large volumes, and thirst. On assessment, the nurse notes that the client
is complaining of mild thirst. On the basis of these findings, the nurse should:
A. Contact the physician
B. Document the findings
C. Institute seizure precautions
D. Have a blood specimen drawn immediately for serum lithium testing (ANS- B.
Document the findings Correct
41 A client with agoraphobia will undergo systematic desensitization through
graduated exposure. In explaining the treatment to the client, the nurse tells the
client that this technique involves:
A. Having the client perform a healthy coping behavior
B. Having the client perform a ritualistic or compulsive behavior
C. Providing a high degree of exposure of the client to the stimulus that the client
finds undesirable
D. Gradually introducing the client to a phobic object or situation in a
predetermined sequence of least to most frightening (ANS- D. Gradually
introducing the client to a phobic object or situation in a predetermined
sequence of least to most frightening
42 A nurse is caring for a client who has just undergone
esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really
thirsty — may I have something to drink?" Before giving the client a drink, the
nurse should:
A. Check the client's vital signs
B. Check for the presence of a gag reflex
C. Assess the client for the presence of bowel sounds
D. Ask the client to gargle with a warm saline solution (ANS- B. Check for the
presence of a gag reflex
43 A nurse is developing a plan of care for a pregnant client with sickle-cell
disease. Which concern does the nurse recognize as the priority?
A. Inability to cope
B. Decreased nutrition
C. Decreased fluid volume
D. Inability to tolerate activity (ANS- C. Decreased fluid volume
44 A nurse is preparing a pregnant client in the third trimester for an amniocentesis.
The nurse explains to the client that amniocentesis is often performed during the
third trimester to determine:
A. The sex of the fetus
B. Genetic characteristics
C. An accurate age for the fetus
D. The degree of fetal lung maturity (ANS- D. The degree of fetal lung maturity
45 A nurse provides instruction to a pregnant woman about foods containing folic
acid. Which of these foods does the nurse tell the client to consume as sources of
folic acid? Select all that apply.
A. Bananas
B. Potatoes
C. Spinach
D. Legumes
E. Whole grains
F. Milk products (ANS- C. Spinach Correct
D. Legumes Correct
E. Whole grains Correct
46 A nurse caring for a client with pre-eclampsia prepares for the administration of
an intravenous infusion of magnesium sulfate. Which of the following substances
does the nurse ensure is available at the client's bedside?
A. Vitamin K
B. Protamine sulfate
C. Potassium chloride
D. Calcium gluconate (ANS- D. Calcium gluconate
47 A nurse is monitoring a client receiving terbutaline (Brethine) by intravenous
infusion to stop preterm labor. The nurse notes that the client's heart rate is 120
beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by
the nurse is:
A. Contacting the physician
B. Documenting the findings
C. Continuing to monitor the client
D. Increasing the rate of the infusion (ANS- A. Contacting the physician
48 A nurse provides home care instructions to a client with mild preeclampsia. The
nurse tells the client that:
A. Sodium intake is restricted
B. Fluid intake must be limited to 1 quart each day
C. Urine output must be measured and that the physician should be notified if
output is less than 500 mL in a 24-hour period
D. Urinary protein must be measured and that the physician should be notified if
the results indicate a trace amount of protein (ANS- C. Urine output must be
measured and that the physician should be notified if output is less than 500 mL
in a 24-hour period
49 A nurse is monitoring a hospitalized client who is being treated for
preeclampsia. Which items of the following information elicited during the
assessment indicate that the condition has not yet resolved? Type the option
number that is the correct answer. (ANS- Answer: __ Correct Responses: "1"____
Nursing Progress Notes
1. Hyperreflexia is present.
2. Urinary protein is not detectable.
3. Urine output is 45 mL/hr.
4. Blood pressure is 128/78 mm Hg.
50 A nurse is caring for a client who sustained a missed abortion during the second
trimester of pregnancy. For which finding indicating the need for further evaluation
does the nurse monitor the client?
A. Spontaneous bruising
B. Decrease in uterine size
C. Urine output of 30 mL/hr
D. Brownish vaginal discharge (ANS- A. Spontaneous bruising
51 A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate
labor. The nurse monitoring the client notes uterine hypertonicity and immediately:
A. Stops the oxytocin infusion Correct
B. Checks the vagina for crowning
C. Encourages the client to take short, deep breaths
D. Increases the rate of the oxytocin infusion and calls the physician (ANS- A.
Stops the oxytocin infusion
52 A nurse is monitoring a pregnant woman in labor and notes this finding on the
fetal-monitor tracing (see figure). Which of the following actions should the nurse
take as a result of this observation?
A. Repositioning the mother
B. Documenting the finding Correct
C. Notifying the nurse-midwife
D. Taking the mother's vital signs (ANS- B. Documenting the finding
53 A client with cervical cancer who is undergoing chemotherapy with cisplatin
(Platinol). For which adverse effect of cisplatin will the nurse assess the client?
A. Nausea
B. Bloody urine
C. Hearing loss
D. Electrocardiographic changes (ANS- C. Hearing loss
54 A nurse is monitoring a pregnant client with suspected partial placenta previa
who is experiencing vaginal bleeding. Which of the following findings would the
nurse expect to note on assessment of the client?
A. Painful vaginal bleeding
B. Sustained tetanic contractions
C. Complaints of abdominal pain
D. Soft, relaxed, nontender uterus (ANS- D. Soft, relaxed, nontender uterus
55 A nurse assisting with a delivery is monitoring the client for placental separation
after the delivery of a viable newborn. Which of the following observations
indicates to the nurse that placental separation has occurred?
A. A discoid uterus
B. Sudden sharp vaginal pain
C. Shortening of the umbilical cord
D. A sudden gush of dark blood from the introitus (ANS- D. A sudden gush of dark
blood from the introitus
56 A nurse is conducting a preoperative psychosocial assessment of a client who is
scheduled for a mastectomy. Which of the following findings would cause the
nurse to conclude that the client is at risk for poor sexual adjustment after the
mastectomy?
A. The client reports a history of sexual abuse by her father.
B. The client reports that her relationship with her spouse is stable.
C. The client reports a satisfying intimate relationship with her spouse.
D. The client reports that her and her spouse have never been able to conceive
children (ANS- A. The client reports a history of sexual abuse by her father.
57 A nurse provides instructions to a client who is preparing for discharge after a
radical vulvectomy for the treatment of cancer. Which statement by the client
indicates a need for further instruction?
A. "I can resume sexual activity in 4 to 6 weeks."
B. "I need to avoid straining when I have a bowel movement."
C. "I should wear support hose for 6 months and elevate my legs frequently." D. "I
need to contact my surgeon immediately if I feel any numbness in my genital
area." (ANS- D. "I need to contact my surgeon immediately if I feel any
numbness in my genital area."
58 An adult client with an ileostomy is admitted to the hospital with a diagnosis of
isotonic dehydration. What findings does the nurse expect to note during the
admission assessment? Select all that apply.
A. Skin tenting
B. Flat neck veins
C. Weak peripheral pulses
D. Moist oral mucous membranes
E. A heart rate of 88 beats/min
F. A respiratory rate of 18 breaths/min (ANS- A. Skin tenting Correct
B. Flat neck veins Correct
C. Weak peripheral pulses Correct
59 An adult client with renal failure who is oliguric and undergoing hemodialysis is
under a fluid restriction of 700 mL/day. How many milliliters of fluid does the
nurse allow the client to have between 7 a.m. and 3 p.m.?Type your answer in the
space provided.
Answer ____mL (ANS- Correct Responses: "350"
60 A client with advanced chronic renal failure (CRF) and oliguria has been taught
about sodium and potassium restriction between dialysis treatments. The nurse
determines that the client understands this restriction if the client states that it is
acceptable to use:
A. Salt substitutes
B. Herbs and spices
C. Salt with cooking only
D. Processed foods as desired (ANS- B. Herbs and spices
61 A nurse provides dietary instruction to a hospitalized client with chronic
obstructive pulmonary disease (COPD). Which of the following menu selections
by the client tells the nurse that the client understands the instructions?
A. Coffee
B. Broccoli
C. Cheeseburger
D. Chocolate milk (ANS- C. Cheeseburger
62 Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's
disease for the relief of choreiform movements. Of which common side effect does
the nurse warn the client?
A. Headache
B. Drowsiness
C. Photophobia
D. Urinary frequency (ANS- B. Drowsiness
63 A client who has sustained an acute myocardial infarction (AMI) is receiving
intravenous reteplase (Retavase). For which adverse effect of the medication does
the nurse monitor the client?
A. Diarrhea
B. Vomiting
C. Epistaxis
D. Epigastric pain (ANS- C. Epistaxis
64 A home care nurse visits a mother who delivered a healthy newborn 4 days ago
and assesses how the mother is doing breastfeeding her infant. What does the nurse
ask the mother to do to permit assessment of whether the infant is receiving an
adequate amount of milk?
A. Count the number of times that the infant swallows during a feeding
B. Weigh the infant every day and check for a daily weight gain of 2 oz
C. Count wet diapers to be sure that the infant is having at least six to 10 each day
D. Pump the breasts, place the milk in a bottle, measure the amount, and then
bottle-feed the infant (ANS- C. Count wet diapers to be sure that the infant is
having at least six to 10 each day
65 A child who has just been found to have scoliosis will need to wear a
thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to
the mother about the brace. Which statement by the mother indicates a need for
further information?
A. "My child will need to do exercises."
B. "My child needs to wear the brace 18 to 23 hours per day."
C. "Wearing the brace is really important in curing the scoliosis."
D. "I need to check my child's skin under the brace to be sure it doesn't break
down." (ANS- C. "Wearing the brace is really important in curing the scoliosis."
66 Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that
it is best to take the medication with:
A. Milk
B. Water
C. Any meal
D. Tomato juice (ANS- D. Tomato juice
67 A client with type 1 diabetes mellitus has just been told that she is 6 weeks
pregnant. The nurse provides information to the client about dietary and insulin
needs and tells the client that during the first trimester, insulin needs generally:
A. Increase
B. Decrease
C. Remain unchanged
D. Double from what they normally are (ANS- B. Decrease
68 A nurse is assessing a pregnant woman for the presence of edema. The nurse
places a thumb on the top of the client's foot, then exerts pressure and releases it
and notes that the thumb has left a persistent depression. On the basis of this
finding, the nurse concludes that:
A. No edema is present
B. The client is dehydrated
C. Pitting edema is present
D. Blood is not pooling in the extremities (ANS- C. Pitting edema is present
69 A nurse assessing the deep tendon reflexes of a pregnant client notes that the
reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the
nurse would:
A. Contact the physician
B. Document the findings
C. Ask the client to walk for 5 minutes, then recheck the reflexes
D. Perform active and passive range-of-motion exercises of the client's lower
extremities, then recheck the reflexes (ANS- B. Document the findings
70 After delivering a normal, healthy newborn, a client complains of severe pelvic
pain and a feeling of extreme fullness in the vagina, and uterine inversion is
suspected. For which immediate intervention does the nurse prepare the client?
A. Hysterectomy
B. Insertion of an indwelling catheter
C. Administration of oxytocin (Pitocin)
D. Replacement of the uterus through the vagina into a normal position (ANS- D.
Replacement of the uterus through the vagina into a normal position
71 A nurse in the postpartum unit is caring for a client who delivered a healthy
newborn 12 hours ago. The nurse checks the client's temperature and notes that it is
100.4° F (38° C). On the basis of this finding, the nurse would:
A. Notify the physician
B. Recheck the temperature in 4 hours
C. Encourage the client to breastfeed the newborn
D. Institute strict bedrest for the client and notify the physician (ANS- B. Recheck
the temperature in 4 hours
72 -A nurse checking the fundus of a postpartum woman notes that it is above the
expected level, at the umbilicus, and that it has shifted from the midline position to
the right. The nurse's initial action should be:
A. Documenting the findings
B. Encouraging the woman to walk
C. Helping the woman empty her bladder Correct
D. Massaging the fundus gently until it becomes firm (ANS- C. Helping the
woman empty her bladder
73-A nurse is preparing to care for a client who was admitted to the antepartum
unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total
placenta previa. In report, the nurse is told that the client's vital signs are stable,
that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the
client and her husband are anxious about the condition of the fetus. On reviewing
the client's plan of care, which client concern does the nurse identify as the priority
at this time?
A. Anxiety Correct
B. Premature grief
C. Fluid volume loss
D. Fluid volume overload (ANS- A. Anxiety
74 -A nurse reviews the laboratory results of a hospitalized pregnant client with a
diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy
(DIC). Which laboratory finding would indicate to the nurse that DIC has
developed in the client?
A. Increased platelet count
B. Shortened prothrombin time
C. Positive result on d-dimer study
D. Decreased fibrin-degradation products (ANS- C. Positive result on d-dimer
study
75 -A nurse is caring for a client with a diagnosis of abruptio placentae. For which
early signs of hypovolemic shock does the nurse closely monitor the client? Select
all that apply.
A. Tachycardia Correct
B. Cool, clammy skin
C. Decreased respiratory rate
D. Diminished peripheral pulses Correct
E. Urine output of less than 30 mL/hr (ANS- A. Tachycardia Correct
D. Diminished peripheral pulses Correct
76- A nurse developing a nursing care plan for a client with abruptio placentae
includes initial nursing measures to be implemented in the event of the
development of shock. After contacting the physician, which of the following does
the nurse specify as the first action in the event of shock?
A. Checking the client's urine output
B. Inserting an intravenous (IV) line
C. Obtaining informed consent for a cesarean delivery
D. Placing the client in a lateral position with the bed flat (ANS- D. Placing the
client in a lateral position with the bed flat
77 -A postpartum nurse provides information to a client who has delivered a
healthy newborn about normal and abnormal characteristics of lochia. Which of the
following findings does the nurse tells the client to report to the physician?
A. Pink lochia on postpartum day 4
B. White lochia on postpartum day 11
C. Bloody lochia on postpartum day 2
D. Reddish lochia on postpartum day 8 (ANS- D. Reddish lochia on postpartum
day 8
78 A nurse in a physician's office is conducting a 2-week postpartum assessment of
a client. During abdominal assessment, the nurse is unable to palpate the uterine
fundus. This finding would prompt the nurse to:
A. Document the findings
B. Ask the physician to see the client immediately
C. Ask another nurse to check for the uterine fundus
D. Place the client in the supine position for 5 minutes, then recheck the abdome
(ANS- A. Document the findings
79- A maternity nurse providing an education session to a group of expectant
mothers describes the purpose of the placenta. Which statement by one of the
women attending the session indicates a need for further discussion of the purpose
of the placenta?
A. "Many of my antibodies are passed through the placenta."
B. "The placenta maintains the body temperature of my baby."
C. "Glucose, vitamins, and electrolytes pass through the placenta."
D. "It provides an exchange of oxygen and carbon dioxide between me and my
baby." (ANS- B. "The placenta maintains the body temperature of my baby."
80 -A client arrives at the clinic for her first prenatal assessment. The client tells
the nurse that the first day of her last menstrual period (LMP) was September 25,
2012. Using Nagele's rule, the nurse determines that the estimated date of delivery
(EDD) is:
A. June 2, 2013
B. July 2, 2013
C. October 2, 2013
D. September 18, 2013 (ANS- B. July 2, 2013
81 A client has been given a prescription for lovastatin (Mevacor). Which of the
following foods does the nurse instruct the client to limit consumption of while
taking this medication?
A. Steak
B. Spinach
C. Chicken
D. Oranges (ANS- A. Steak
82 -A nurse is reviewing the laboratory results of a client with ovarian cancer who
is undergoing chemotherapy. Which finding indicates to the nurse that the client is
experiencing an adverse effect of the chemotherapy?
A. Sodium 140 mEq/L
B. Hemoglobin 12.5 g/dL
C. Blood urea nitrogen (BUN) 20 mg/dL
D. White blood cell count of 2500 cells/mm3 (ANS- D. White blood cell count of
2500 cells/mm3
83 -Which finding in a client's history indicates the greatest risk of cervical cancer
to the nurse?
A. Nulliparity
B. Early menarche
C. Multiple sexual partners Correct
D. Hormone-replacement therapy (ANS- C. Multiple sexual partners
84 -A nurse caring for a woman in labor is reading the fetal monitor tracing (see
figure). How does the nurse interpret this finding?
A. Umbilical cord compression
B. Pressure on the fetal head during a contraction
C. Uteroplacental insufficiency during a contraction Correct
D. Inadequate pacemaker activity of the fetal heart (ANS- C. Uteroplacental
insufficiency during a contraction
85- A client who has undergone abdominal hysterectomy asks the nurse when she
will be able to resume sexual intercourse. The nurse tells the client that sexual
intercourse may be resumed:
A. At any time after the surgery
B. When menstruation resumes
C. When pelvic sensation and response to stimuli return
D. In about 6 weeks, when the vaginal vault is satisfactorily healed (ANS- D. In
about 6 weeks, when the vaginal vault is satisfactorily healed
86 -A nurse is preparing to care for a client who has undergone abdominal
hysterectomy for the treatment of endometrial cancer. The nurse determines that
the priority in the 24 hours after surgery is:
A. Monitoring the client for signs of returning peristalsis
B. Instructing the client in dietary changes to prevent constipation
C. Encouraging the client to deep-breathe, cough, and use an incentive spirometer
Correct
D. Encouraging the client to talk about the effects of the surgery on her femininity
and sexual (ANS- C. Encouraging the client to deep-breathe, cough, and use an
incentive spirometer
87- A nurse is caring for a client with community-acquired pneumonia who is
being treated with levofloxacin (Levaquin). For which of the following findings,
indicating an adverse reaction to the medication, does the nurse monitor the client?
A. Fever
B. Dizziness
C. Flatulence
D. Drowsiness (ANS- A. Fever
88 -A nurse is providing instructions to a client with glaucoma who will be using
acetazolamide (Diamox) daily. Which of the following findings, an adverse effect,
does the nurse instruct the client to report to the physician?
A. Nausea
B. Dark urine
C. Urinary frequency
D. Decreased appetite (ANS- B. Dark urine
89 -A nurse is caring for a client with a cuffed endotracheal tube who is undergoing
mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula,
a complication of this type of tube, does the nurse implement?
A. Frequent suctioning
B. Maintaining cuff pressure
C. Maintaining mechanical ventilation settings
D. Alternating the use of a cuffed tube with a cuffless tube on a daily basis (ANSB. Maintaining cuff pressure
90 - A nurse is preparing to insert a nasogastric tube into a client. In which position
does the nurse place the client before inserting the tube?
SEE PIC
A.
B.
C.
D. (ANS- D.
91 -Aneurysm precautions are prescribed for a client with a cerebral aneurysm.
Which interventions does the nurse implement? Select all that apply
A. Keeping the room slightly darkened
B. Placing the client in a room with a quiet roommate
C. Encouraging isometric exercises if bed rest is prescribed
D. Monitoring the client for changes in alertness or mental status
E. Restricting visits to close family members and significant others and keeping
visits short (ANS- A. Keeping the room slightly darkened Correct D.
Monitoring the client for changes in alertness or mental status Correct
E. Restricting visits to close family members and significant others and keeping
visits short Correct
92 -A nurse, providing information to a client who has just been found to have
diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which of
the following answers by the client, on being asked to list the symptoms, tells the
nurse that the client understands the information? Select all that apply.
A. Hunger
B. Weakness
C. Blurred vision
D. Increased thirst
E. Increased urine output (ANS- A. Hunger Correct
B. Weakness Correct
C. Blurred vision Correct
93- A nurse is planning to teach a crutch gait to a client who will be using wooden
axillary crutches. The nurse reviews the physician's instructions, understanding that
the gait was selected after assessment of the client's:
A. Physical and functional abilities
B. Feelings about restricted mobility
C. Uneasiness about using the crutches
D. Understanding of the need for increased mobility (ANS- A. Physical and
functional abilities
94- A client who has undergone extensive gastrointestinal surgery is receiving
intermittent enteral tube feedings that will be continued after he is discharged
home. When the nurse tells the client that he will be taught how to administer the
feedings, the client states, "I don't think I'll be able to do these feedings by myself."
Which response by the nurse is appropriate?
A. "Have you told your doctor how you feel?"
B. "Tell me more about your concerns regarding the tube feedings."
C. "Don't worry. We'll keep you in the hospital until you're ready to do them by
yourself."
D. "We'll ask the doctor about having a visiting nurse come to your home to give
you your feedings." (ANS- B. "Tell me more about your concerns regarding the
tube feedings."
95- A client is brought to the emergency department after sustaining smoke
inhalation. Humidified oxygen is administered to the client by way of face mask,
and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial
oxygenation (Pao2) of less than 60 mm Hg. On the basis of the ABG result, the
nurse prepares to:
A. Continue monitoring the client
B. Increase the amount of humidified oxygen
C. Continue administering humidified oxygen
D. Assist in intubating the client and beginning mechanical ventilation (ANS- D.
Assist in intubating the client and beginning mechanical ventilation
96- A nurse is caring for a client undergoing skeletal traction of the left leg. The
client complains of severe pain in the leg. The nurse checks the client's alignment
in bed and notes that proper alignment is being maintained. Which of the following
actions should the nurse take next?
A. Providing pin care
B. Medicating the client
C. Notifying the physician Correct
D. Removing some weight from the traction (ANS- C. Notifying the physician
97 -A clinic nurse is assessing a client who has had a cast applied to the lower left
arm 1 week ago. The client tells the nurse that the skin is being irritated by the
edges of the cast. What is the appropriate action on the part of the nurse
A. Bivalve the cast
B. Ask the physician to reapply the cast
C. Use a nail file to smooth the rough edges
D. Place small pieces of tape over the rough edges of the cast (ANS- D. Place
small pieces of tape over the rough edges of the cast
98 -A client says to the nurse, "My doctor just left. He told me that my abdominal
scan showed a mass in my pancreas and that it's probably cancer. Does this mean
I'm going to die?" The nurse interprets the client's initial reaction as:
A. Fear
B. Denial
C. Acceptance
D. Preoccupation with self (ANS- A. Fear
99 -A nurse notes documentation in the client's medical record indicating that the
client has a stage II pressure ulcer. On the basis of this information, which of the
following findings does the nurse expect to note?
A.
B.
C.
D. (ANS- B. Correct
100- A nurse is providing instruction in how to perform Kegel exercises to a client
with stress incontinence. The nurse tells the client to:
A. Always perform the exercises while lying down
B. Expect an improvement in the control of urine in about 1 week
C. Tighten the pelvic muscles for as long as 5 minutes, three or four times a day
D. Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of
10 (ANS- D. Tighten the pelvic muscles for a slow count of 10, then relax for a
slow count of 10
101 -Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which
of the following occurrences does the nurse tell the client to report to the physician
if she experiences them while taking the medication?
A. Cough
B. Fatigue and lethargy
C. Dizziness and fatigue
D. Numbness and tingling of the fingers or toes (ANS- D. Numbness and tingling
of the fingers or toes
102 -A client with post-traumatic stress disorder tells the nurse that he has stopped
taking his prescribed medication because he didn't like how the medication was
making him feel. Which of the following initial responses by the nurse is
appropriate?
A. "That's all right. I'd stop, too, if it made me feel funny."
B. "Tell me more about how the medication was making you feel."
C. "Did you let your doctor know that you stopped taking the medication?" D. "It
doesn't make sense to stop the medication. I don't know why you took it upon
yourself to do that." (ANS- B. "Tell me more about how the medication was
making you feel."
103- A nurse provides information to a client with peripheral vascular disease
about ways to limit the disease's progression. Which of the following measures
does the nurse tell the client to take? Select all that apply.
A. Crossing the legs at the ankles only
B. Engaging in exercise such as walking on a daily basis
C. Washing the feet daily with a mild soap and drying them well
D. Inspecting the feet at least once a week for injuries, especially abrasions
E. Using a heating pad on the legs to help keep the blood vessels dilated (ANS- B.
Engaging in exercise such as walking on a daily basis Correct
C. Washing the feet daily with a mild soap and drying them well Correct
104 -A client with depression is anorexic. Which measure does the nurse take to
assist the client in meeting nutritional needs?
A. Providing food and fluid as the client requests
B. Offering high-calorie and high-protein foods and fluids frequently throughout
the day
C. Completing the dietary menu for the client to ensure that adequate nutrition is
provided
D. Weighing the client daily so that the client may determine whether the
nutritional plan is working (ANS- B. Offering high-calorie and high-protein
foods and fluids frequently throughout the day
105 -Disulfiram (Antabuse) is prescribed to a client with an alcohol abuse problem.
The nurse provides information about the medication and tells the client:
A. That driving is prohibited while the client is taking the medication
B. To take the medication immediately if the desire to drink alcohol occurs C.
That the effect of the medication ends as soon as the client stops taking the
medication
D. That the medication cannot be started until at least 12 hours has elapsed since
the client's last ingestion of alcohol (ANS- D. That the medication cannot be
started until at least 12 hours has elapsed since the client's last ingestion of alcohol
106 A client with depression is being encouraged to attend art therapy as part of the
treatment plan. The client refuses, stating, "I can't draw or paint." Which of the
following responses by the nurse is therapeutic?
A. "Why don't you really want to attend?"
B. "This is what your physician has prescribed for you as part of the treatment
plan."
C. "OK, let's have you attend music therapy. You can sing there. How does that
sound?"
D. "Perhaps you could attend and talk to the other clients and see what they're
drawing and painting." (ANS- D. "Perhaps you could attend and talk to the
other clients and see what they're drawing and painting." [Show Less]