HESI 102 RN HESI EXIT EXAM 3 100 Questions and Answers Spring 2022- Chamberlain College of Nursing
RN HESI EXIT EXAM
RN HESI EXIT EXAM
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RN HESI EXIT
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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 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 to 2 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 with 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
(ANS- 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
(ANS- 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
(ANS- 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."
(ANS- 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
(ANS- 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
(ANS- 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
(ANS- 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
(ANS- 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
(ANS- 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
(ANS- 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
(ANS- 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.
(ANS- 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.
(ANS- 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
(ANS- 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
(ANS- 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."
(ANS- 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
(ANS- The correct answer is A: S3 ventricular gallop
30. Which of these observations made by the nurse during an excretory urogram
indicate a complication?
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."
(ANS- 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."
(ANS- 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
(ANS- 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
(ANS- 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
(ANS- 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
B) complaint of nausea
C) pulse rate of 92
D) restlessness
(ANS- The correct answer is D: restlessness
36. The most effective nursing intervention to prevent atelectasis from developing
in a post operative client is to
A) Maintain adequate hydration
B) Assist client to turn, deep breathe, and cough
C) Ambulate client within 12 hours
D) Splint incision
(ANS- The correct answer is B: Assist client to turn, deep breathe, and cough
37. When caring for a client with a post right thoracotomy who has undergone an
upper
lobectomy, the nurse focuses on pain management to promote
A) Relaxation and sleep
B) Deep breathing and coughing
C) Incisional healing
D) Range of motion exercises
(ANS- The correct answer is B: Deep breathing and coughing
38. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a
client. Which action should the nurse take first? A) Ask client to cough sputum
into container
B) Have the client take several deep breaths
C) Provide a appropriate specimen container
D) Assist with oral hygiene
(ANS- The correct answer is D: Assist with oral hygiene
39. The nurse is caring for a child immediately after surgical correction of a
ventricular septal defect. Which of the following nursing assessments should be a
priority?
A) Blanch nail beds for color and refill
B) Assess for post operative arrhythmias
C) Auscultate for pulmonary congestion
D) Monitor equality of peripheral pulses
(ANS- The correct answer is B: Assess for post operative arrhythmias
40. A client has a history of chronic obstructive pulmonary disease (COPD). As the
nurse enters the client's room, his oxygen is running at 6 liters per minute, his color
is flushed and his respirations are 8 per minute. What should the nurse do first?
A) Obtain a 12-lead EKG
B) Place client in high Fowler's position
C) Lower the oxygen rate
D) Take baseline vital signs
(ANS- The correct answer is C: Lower the oxygen rate
41. A 4 year-old has been hospitalized for 24 hours with skeletal traction for
treatment of a fracture of the right femur. The nurse finds that the child is now
crying and the right foot is pale with the absence of a pulse. What should the nurse
do first?
A) Notify the health care provider
B) Read just the traction
C) Administer the ordered prn medication
D) Reassess the foot in fifteen minutes
(ANS- The correct answer is A: Notify the health care provider
42. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal
bypass. The upper leg dressing becomes saturated with blood. The nurse's first
action should be to
A) Wrap the leg with elastic bandages
B) Apply pressure at the bleeding site
C) Reinforce the dressing and elevate the leg
D) Remove the dressings and re-dress the incision
(ANS- The correct answer is C: Reinforce the dressing and elevate the leg
43. A client is receiving external beam radiation to the mediastinum for treatment
of bronchial cancer. Which of the following should take priority in planning care?
A) Esophagitis
B) Leukopenia
C) Fatigue
D) Skin irritation
(ANS- Review Information: The correct answer is B: Leukopenia
44. A client has a chest tube in place following a left lower lobectomy inserted
after a stab wound to the chest. When repositioning the client, the nurse notices
200 cc of dark, red fluid flows into the collection chamber of the chest drain. What
is the most appropriate nursing action?
A) Clamp the chest tube
B) Call the surgeon immediately
C) Prepare for blood transfusion
D) Continue to monitor the rate of drainage (ANS- The correct answer is D:
Continue to monitor the rate of drainage
45. A client has returned from a cardiac catheterization. Which one of the
following assessments would indicate the client is experiencing a
complication from the procedure?
A) Increased blood pressure
B) Increased heart rate
C) Loss of pulse in the extremity
D) Decreased urine output
(ANS- The correct answer is C: Loss of pulse in the extremity
46. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He
is awake and alert, but has not been able to void since he returned from surgery 6
hours ago. He received 1000 mL of IV fluid. Which action would be most likely to
help him void?
A) Have him drink several glasses of water
B) Crede' the bladder from the bottom to the top
C) Assist him to stand by the side of the bed to void
D) Wait 2 hours and have him try to void again
(ANS- The correct answer is C: Assist him to stand by the side of the bed to void
47. The nurse is caring for a client who requires a mechanical ventilator for
breathing. The high pressure alarm goes off on the ventilator. What is the first
action the nurse should perform?
A) Disconnect the client from the ventilator and use a manual resuscitation bag
B) Perform a quick assessment of the client's condition
C) Call the respiratory therapist for help
D) Press the alarm re-set button on the ventilator
(ANS- The correct answer is B: Perform a quick assessment of the client''s
condition
48. The nurse is preparing a client who will undergo a myelogram. Which of the
following statements by the client indicates a contraindication for this test?
A) "I can't lie in 1 position for more than thirty minutes."
B) "I am allergic to shrimp."
C) "I suffer from claustrophobia."
D) "I developed a severe headache after a spinal tap."
(ANS- The correct answer is B: "I am allergic to shrimp."
49. The health care provider order reads "aspirate nasogastric feeding (NG) tuber
every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which
action should the nurse take?
A) Hold the tube feeding and notify the provider
B) Administer the tube feeding as scheduled
C) Irrigate the tube with diet cola soda
D) Apply intermittent suction to the feeding tube
(ANS- The correct answer is A: Hold the tube feeding and notify the provider
50. To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse
must
A) Apply suction for no more than 10 seconds
B) Maintain sterile technique
C) Lubricate 3 to 4 inches of the catheter tip
D) Withdraw catheter in a circular motion
(ANS- Applying suction for more than 10 seconds
51. An antibiotic IM injection for a 2 year-old child is ordered. The total volume of
the injection equals 2.0 ml The correct action is to A) administer the medication in
2 separate injections
B) give the medication in the dorsal gluteal site
C) call to get a smaller volume ordered
D) check with pharmacy for a liquid form of the medication skip
(ANS- The correct answer is A: administer the medication in 2 separate injections
52. The nurse receives an order to give a client iron by deep injection. The nurse
know
that the reason for this route is to
A) enhance absorption of the medication
B) ensure that the entire dose of medication is given
C) provide more even distribution of the drug
D) prevent the drug from tissue irritation
(ANS- The correct answer is D: prevent the drug from tissue irritation
53. A client with heart failure has Lanoxin (digoxin) ordered. What would the
nurse expect to find when evaluating for the therapeutic effectiveness of this drug?
A) diaphoresis with decreased urinary output
B) increased heart rate with increase respirations
C) improved respiratory status and increased urinary output
D) decreased chest pain and decreased blood pressure (ANS- The correct answer is
C: improved respiratory status and increased urinary output
54. While providing home care to a client with congestive heart failure, the nurse is
asked how long diuretics must be taken. What is the nurse's best response?
A) "As you urinate more, you will need less medication to control fluid."
B) "You will have to take this medication for about a year."
C) "The medication must be continued so the fluid problem is controlled."
D) "Please talk to your health care provider about medications and treatments."
(ANS- The correct answer is C: "The medication must be continued so the fluid
problem is controlled."
55. A client is being discharged with a prescription for chlorpromazine
(Thorazine).
Before leaving for home, which of these findings should the nurse teach the client
to report?
A) Change in libido, breast enlargement
B) Sore throat, fever
C) Abdominal pain, nausea, diarrhea
D) Dsypnea, nasal congestion
(ANS- The correct answer is B: Sore throat, fever
56. A client is recovering from a hip replacement and is taking Tylenol #3 every 3
hours for pain. In checking the client, which finding suggests a side effect of the
analgesic?
A) Bruising at the operative site
B) Elevated heart rate
C) Decreased platelet count
D) No bowel movement for 3 days Skip
(ANS- The correct answer is D: No bowel movement for 3 days
57. A client is being maintained on heparin therapy for deep vein thrombosis. The
nurse must closely monitor which of the following laboratory values?
A) Bleeding time
B) Platelet count
C) Activated PTT
D) Clotting time
(ANS- The correct answer is C: Activated PTT
58. A client with amyotrophic lateral sclerosis has a percutaneous endoscopic
gastrostomy (PEG) tube for the administration of feedings and medications. Which
nursing action is appropriate?
A) Pulverize all medications to a powdery condition
B) Squeeze the tube before using it to break up stagnant liquids
C) Cleanse the skin around the tube daily with hydrogen peroxide
D) Flush adequately with water before and after using the tube Skip
(ANS- The correct answer is D: Flush adequately with water before and after using
the tube
59. The nurse has given discharge instructions to parents of a child on phenytoin
(Dilantin). Which of the following statements suggests that the teaching was
effective?
A) "We will call the health care provider if the child develops acne."
B) "Our child should brush and floss carefully after every meal."
C) "We will skip the next dose if vomiting or fever occur."
D) "When our child is seizure-free for 6 months, we can stop the medication."
(ANS- The correct answer is B: "Our child should brush and floss carefully
after every meal."
60. Although non steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are
beneficial in managing arthritis pain, the nurse should caution clients about which
of the following common side effects?
A) Urinary incontinence
B) Constipation
C) Nystagmus
D) Occult bleeding
(ANS- The correct answer is D: Occult bleeding
61. The nurse is caring for a client with clinical depression who is receiving a
MAO
inhibitor. When providing instructions about precautions with this medication,
which action should the nurse stress to the client as important? A) Avoid
chocolate and cheese
B) Take frequent naps
C) Take the medication with milk
D) Avoid walking without assistance
(ANS- The correct answer is A: Avoid chocolate and cheese
62. A parent asks the school nurse how to eliminate lice from their child. What is
the most appropriate response by the nurse? A) Cut the child's hair short to
remove the nits
B) Apply warm soaks to the head twice daily
C) Wash the child's linen and clothing in a bleach solution D)
Application of pediculicides
(ANS- The correct answer is D: Application of pediculicides
63. The nurse is teaching a client about precautions with Coumadin therapy. The
client should be instructed to avoid which over-the-counter medication?
A) Non-steroidal anti-inflammatory drugs
B) Cough medicines with guaifenesin
C) Histamine blockers
D) Laxatives containing magnesium salts
(ANS- The correct answer is A: Non-steroidal anti inflammatory drugs
64. A client diagnosed with cirrhosis of the liver and ascites is receiving
Spironolactone
(Aldactone). The nurse understands that this medication spares elimination of
which element?
A) Sodium
B) Potassium
C) Phosphate
D) Albumin
(ANS- The correct answer is B: Potassium
65. The nurse is caring for a client receiving a blood transfusion who develops
urticaria one-half hour after the transfusion has begun. What is the first action the
nurse should take?
A) Stop the infusion
B) Slow the rate of infusion
C) Take vital signs and observe for further deterioration
D) Administer Benadryl and continue the infusion
(ANS- The correct answer is A: Stop the infusion
66. Discharge instructions for a client taking alprazolam (Xanax) should include
which of the following?
A) Sedative hypnotics are effective analgesics
B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and
nightmares
C) Caffeine beverages can increase the effect of sedative hypnotics
D) Avoidance of excessive exercise and high temperature is recommended (ANSThe correct answer is B: Sudden cessation of alprazolam
67. A client has received 2 units of whole blood today following an episode of GI
bleeding. Which of the following laboratory reports would the nurse monitor most
closely?
A) Bleeding time
B) Hemoglobin and hematocrit
C) White blood cells
D) Platelets
(ANS- The correct answer is B: Hemoglobin and hematocrit
68. A client is receiving intravenous heparin therapy. What medication should the
nurse have available in the event of an overdose of heparin?
A) Protamine
B) Amicar
C) Imferon
D) Diltiazem
(ANS- The correct answer is A: Protamine . Protamine binds heparin making it
ineffective.
69. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus.
Which statement by the client indicates a need for further teaching?
A) "I use a sliding scale to adjust regular insulin to my sugar level."
B) "Since my eyesight is so bad, I ask the nurse to fill several syringes."
C) "I keep my regular insulin bottle in the refrigerator."
D) "I always make sure to shake the NPH bottle hard to mix it well."
(ANS- The correct answer is D: "I always make sure to shake the NPH bottle hard
to mix it well."
70. Why is it important for the nurse to monitor blood pressure in clients receiving
antipsychotic drugs?
A) Orthostatic hypotension is a common side effect
B) Most antipsychotic drugs cause elevated blood pressure
C) This provides information on the amount of sodium allowed in the diet
D) It will indicate the need to institute anti parkinsonian drugs
(ANS- The correct answer is A: Orthostatic hypotension is a common side effect
71. The nurse is teaching the client to select foods rich in potassium to help prevent
digitalis toxicity. Which choice indicates the client understands dietary needs?
A) Three apricots
B) Medium banana
C) Naval orange
D) Baked potato
(ANS- The correct answer is D: Baked potato.
72. An 86 year-old nursing home resident who has decreased mental status is
hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse
assists the client with a clear liquid diet, the client begins to cough. What should
the nurse do next?
A) Add a thickening agent to the fluids
B) Check the client's gag reflex
C) Feed the client only solid foods
D) Increase the rate of intravenous fluids
(ANS- The correct answer is B: Check the client's gag reflex
73. The nurse is planning care for a client with a CVA. Which of the following
measures planned by the nurse would be most effective in preventing skin
breakdown?
A) Place client in the wheelchair for four hours each day
B) Pad the bony prominence
C) Reposition every two hours
D) Massage reddened bony prominence
(ANS- The correct answer is C: Reposition every two hours
74. A nurse is assessing several clients in a long term health care facility. Which
client is at highest risk for development of decubitus ulcers?
A) A 79 year-old malnourished client on bed rest
B) An obese client who uses a wheelchair
C) A client who had 3 incontinent diarrhea stools
D) An 80 year-old ambulatory diabetic client
(ANS- The correct answer is A: A 79 year-old malnourished client on bed rest
75. Constipation is one of the most frequent complaints of elders. When assessing
this problem, which action should be the nurse's priority?
A) Obtain a complete blood count
B) Obtain a health and dietary history
C) Refer to a provider for a physical examination
D) Measure height and weight
(ANS- The correct answer is B: Obtain a health and dietary history
76. After a client has an enteral feeding tube inserted, the most accurate method for
verification of placement is
A) Abdominal x-ray
B) Auscultation
C) Flushing tube with saline
D) Aspiration for gastric contents
(ANS- D) Aspiration for gastric contents
The correct answer is A: Abdominal x-ray
77. A client was just taken off the ventilator after surgery and has a nasogastric
tube draining bile colored liquids. Which nursing measure will provide the
most comfort to the client?
A) Allow the client to melt ice chips in the mouth
B) Provide mints to freshen the breath
C) Perform frequent oral care with a tooth sponge
D) Swab the mouth with glycerin swabs
(ANS- The correct answer is C: Perform frequent oral care with a tooth sponge
78. The nurse is instructing a 65 year-old female client diagnosed with
osteoporosis. The most important instruction regarding exercise would be to
A) Exercise doing weight bearing activities
B) Exercise to reduce weight
C) Avoid exercise activities that increase the risk of fracture
D) Exercise to strengthen muscles and thereby protect bones
(ANS- The correct answer is A: Exercise doing weight bearing activities
79. The nurse has been teaching a client with congestive heart failure about proper
nutrition. The selection of which lunch indicates the client has learned about
sodium restriction?
A)Cheese sandwich with a glass of 2% milk
B) Sliced turkey sandwich and canned pineapple
C) Cheeseburger and baked potato
D) Mushroom pizza and ice cream
(ANS- The correct answer is B: Sliced turkey sandwich and canned pineapple
80. Which bed position is preferred for use with a client in an extended care facility
on falls risk prevention protocol?
A) All 4 side rails up, wheels locked, bed closest to door
B) Lower side rails up, bed facing doorway
C) Knees bent, head slightly elevated, bed in lowest position
D) Bed in lowest position, wheels locked, place bed against wall
(ANS- The correct answer is D: Bed in lowest position, wheels locked, place bed
against wall
81. When administering enteral feeding to a client via a jejunostomy tube, the
nurse
should administer the formula
A) Every four to six hours
B) Continuously
C) In a bolus
D) Every hour
(ANS- The correct answer is B: Continuously
82. The nurse is teaching an 87 year-old client methods for maintaining regular
bowel
movements. The nurse would caution the client to AVOID
A) Glycerine suppositories
B) Fiber supplements
C) Laxatives
D) Stool softeners
(ANS- The correct answer is C: Laxatives
83. A client with diarrhea should avoid which of the following?
A) Orange juice
B) Tuna
C) Eggs
D) Macaroni
(ANS- The correct answer is A: Orange juice
84. Which statement best describes the effects of immobility in children?
A) Immobility prevents the progression of language and fine motor development
B) Immobility in children has similar physical effects to those found in adults
C) Children are more susceptible to the effects of immobility than are adults D)
Children are likely to have prolonged immobility with subsequent
complications
(ANS- The correct answer is B: Immobility in children has similar physical effects
to those
found in adults
85. A nurse is providing care to a 63 year-old client with pneumonia. Which
intervention promotes the client's comfort?
A) Increase oral fluid intake
B) Encourage visits from family and friends
C) Keep conversations short
D) Monitor vital signs frequently
(ANS- The correct answer is C: Keep conversations short
86. After a myocardial infarction, a client is placed on a sodium restricted diet.
When the nurse is teaching the client about the diet, which meal plan would be the
most appropriate
A) 3 oz. broiled fish, 1 baked potato, . cup canned beets, 1 orange, and milk B)
3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple
C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice
D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange
(ANS- The correct answer is D: 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh
green beans, milk, and 1 orange
87. The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN).
Findings include moderate edema and oliguria. Serum blood urea nitrogen and
creatinine are elevated. What dietary modifications are most appropriate?
A) Decreased carbohydrates and fat
B) Decreased sodium and potassium
C) Increased potassium and protein
D) Increased sodium and fluids
(ANS- The correct answer is B: Decreased sodium and potassium
88. What nursing assessment of a paralyzed client would indicate the probable
presence of a fecal impaction?
A) Presence of blood in stools
B) Oozing liquid stool
C) Continuous rumbling flatulence
D) Absence of bowel movements
(ANS- The correct answer is B: Oozing liquid stool
89. A client in a long term care facility complains of pain. The nurse collects data
about the client's pain. The first step in pain assessment is for the nurse to
A) have the client identify coping methods
B) get the description of the location and intensity of the pain
C) accept the client's report of pain
D) determine the client's status of pain (
ANS- The correct answer is C: Accept the client''s report of pain
90. An 85 year-old client complains of generalized muscle aches and pains. The
first action by the nurse should be
A) Assess the severity and location of the pain
B) Obtain an order for an analgesic
C) Reassure him that this is not unusual for his age
D) Encourage him to increase his activity
(ANS- The correct answer is A: Assess the severity and location of the pain
91. A 20 year-old client has an infected leg wound from a motorcycle accident, and
the client has returned home from the hospital. The client is to keep the affected
leg elevated and is on contact precautions. The client wants to know if visitors can
come. The appropriate response from the home health nurse is that: A) Visitors
must wear a mask and a gown
B) There are no special requirements for visitors of clients on contact precautions
C) Visitors should wash their hands before and after touching the client
D) Visitors
(ANS- The correct answer is C:Visitors should wash their hands before and after
touching the client
92. A child is admitted to the pediatric unit with a diagnosis of suspected
meningococcal meningitis. Which admission orders should the nurse do
first?
A) Institute seizure precautions
B) Monitor neurologic status every hour
C) Place in respiratory/secretion precautions
D) Cefotaxime IV 50 mg/kg/day divided q6h
(ANS- The correct answer is C: Place in respiratory/secretion precautions
93. Which of these nursing diagnoses of 4 elderly clients would place 1 client at
the greatest risk for falls?
A) Sensory perceptual alterations related to decreased vision
B) Alteration in mobility related to fatigue
C) Impaired gas exchange related to retained secretions
D) Altered patterns of urinary elimination related to nocturia
(ANS- The correct answer is D: Altered patterns of urinary elimination related to
nocturia
94. A nurse who is reassigned to the emergency department needs to understand
that
gastric lavage is a priority in which situation? A) An
infant who has been identified to have botulism
B) A toddler who ate a number of ibuprofen tablets
C) A preschooler who swallowed powdered plant food
D) A school aged child who took a handful of vitamins
(ANS- The correct answer is A: An infant who has been identified to have botulism
95. A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse
should reinforce to the staff members that the most significant routine infection
control strategy, in addition to hand washing, to be implemented is which of these?
A) Apply appropriate signs outside and inside the room
B) Apply a mask with a shield if there is a risk of fluid splash
C) Wear a gown to change soiled linens from incontinence
D) Have gloves on while handling bedpans with feces
(ANS- The correct answer is D: Have gloves on while handling bedpans with feces
96. Which of these clients with associated lab reports is a priority for the nurse to
report to the public health department within the next 24 hours?
A) An infant with a positive culture of stool for Shigella
B) An elderly factory worker with a lab report that is positive for acid-fast bacillus
smear
C) A young adult commercial pilot with a positive histopathological examination
from an induced sputum for Pneumocystis carinii
D) A middle-aged nurse with a history of varicella-zoster virus and with crops of
vesicles on an erythematous base that appear on the skin
(ANS- The correct answer is B: An elderly factory worker with a lab report that is
positive for acid-fast bacillus smear
97. A client is diagnosed with methicillin resistant staphylococcus aureus
pneumonia. What type of isolation is most appropriate for this client?
A) Reverse
B) Airborne
C) Standard precautions
D) Contac
(ANS- The correct answer is D: Contact
98. The school nurse is teaching the faculty the most effective methods to prevent
the spread of lice in the school. The information that would be most important to
include would be which of these statements?
A) "The treatment requires reapplication in 8 to 10
days."
B) "Bedding and clothing can be boiled or steamed."
C) Children are not to share hats, scarves and
combs.
D) Nit combs are necessary to comb out nits.
(ANS- The correct answer is C: "Children are not to share hats, scarves and
combs."
99. During the care of a client with a salmonella infection, the primary nursing
intervention to limit transmission is which of these approaches?
A) Wash hands thoroughly before and after client contact
B) Wear gloves when in contact with body secretions
C) Double glove when in contact with feces or vomitus
D) Wear gloves when disposing of contaminated linens
(ANS- The correct answer is A: Wash hands thoroughly before and after client
contact
100. A nurse is reinforcing teaching with a client about compromised host
precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The
selection of which lunch suggests the client has learned about necessary dietary
changes?
A) grilled chicken sandwich and skim milk
B) roast beef, mashed potatoes, and green beans
C) peanut butter sandwich, banana, and iced tea
D) barbecue beef, baked beans, and cole slaw
(ANS- The correct answer is B: roast beef, mashed potatoes, and green beans [Show Less]