MDA 224 2019 HESI EXIT V2 (COMPLETE SOLUTION)
2019 HESI EXIT V2
1. The nurse knows that which statement by the mother indicates that
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mother
understands safety precautions with her four month-old infant and her 4
year-old child?
A) "I strap the infant car seat on the front seat to face backwards."
B) "I place my infant in the middle of the living room floor on a blanket to
play with my
4 year old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocks stuck
up in the air
while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old a bottle in
the kitchen
while I make supper."
The correct answer is D: "I have the four year-old hold and help feed the
four month-old
a bottle in the kitchen
2. Upon completing the admission documents, the nurse learns that the
87 year-old client
does not have an advance directive. What action should the nurse take?
A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary
The correct answer is B: Give information about advance directives
3. A nurse administers the influenza vaccine to a client in a clinic. Within
15 minutes after
the immunization was given, the client complains of itchy and watery
eyes, increased
anxiety, and difculty breathing. The nurse expects that the frst action in
the sequence of
care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered
The correct answer is B: Administer epinephrine 1:1000 as ordered .
4. Which of these children at the site of a disaster at a child day care
center would the
triage nurse put in the "treat last" category?
A) An infant with intermittent bulging anterior fontanel between crying
episodesB) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with an upper
leg fracture
D) A school-age child with singed eyebrows and hair on the arms
The correct answer is B: A toddler with severe deep abrasions over 98% of
the body .
5. When admitting a client to an acute care facility, an identifcation
bracelet is sent up
with the admission form. In the event these do not match, the nurse’s
best action is to
A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement is supplied
C) Notify the admissions ofce and wait to apply the bracelet
D) Make a corrected identifcation bracelet for the client
The correct answer is C: notify the admissions ofce and wait to apply the
bracelet
6. The nurse is having difculty reading the health care provider's written
order that was
written right before the shift change. What action should be taken?
A) Leave the order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarifcation
The correct answer is D: Call the provider for clarifcation
7. An adult client is found to be unresponsive on morning rounds. After
checking for
responsiveness and calling for help, the next action that should be taken
by the nurse is
to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway
The correct answer is D: open the client''s airway
8. A client has an order for 1000 ml of D5W over an 8 hour period. The
nurse discovers
that 800 ml has been infused after 4 hours. What is the priority nursing
action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs
The correct answer is D: Auscultate the lungs9. Following change-of-shift report on an orthopedic unit, which client
should the nurse
see frst?
A) 16 year-old who had an open reduction of a fractured wrist 10 hours
ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours
ago
D) 75 year-old who is in skin traction prior to planned hip pinning surgery.
The correct answer is C: 72 year-old recovering from surgery after a hip
replacement 2
hours ago
10. A nurse observes a family member administer a rectal suppository by
having the
client lie on the left side for the administration. The family member
pushed the
suppository until the fnger went up to the second knuckle. After 10
minutes the client
was told by the family member to turn to the right side and the client did
this. What is the
appropriate comment for the nurse to make?
A) Why don’t we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with the insertion?
C) Let’s check to see if the suppository is in far enough.
D) Did you feel any stool in the intestinal tract?
The correct answer is B: That was done correctly. Did you have any
problems with the
insertion?
11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus
(MRSA) has
died. Which type of precautions is the appropriate type to use when
performing
postmortem care?
A) airborne precautions
B) droplet precautions
C) contact precautions
D) compromised host precautions
The correct answer is C: contact precautions
12. The nurse is reviewing with a client how to collect a clean catch urine
specimen.
Which sequence is appropriate teaching?
A) Void a little, clean the meatus, then collect specimen
B) clean the meatus, begin voiding, then catch urine stream
C) Clean the meatus, then urinate into containerD) Void continuously and catch some of the urine
The correct answer is B: clean the meatus, begin voiding, then catch urine
stream
13. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40
mg every
day. Which of these foods would the nurse reinforce for the client to eat at
least daily?
A) spaghetti
B) watermelon
C) chicken
D) tomatoes
The correct answer is B: watermelon
14. A nurse is stuck in the hand by an exposed needle. What immediate
action should the
nurse take?
A) Look up the policy on needle sticks
B) Contact employee health services
C) Immediately wash the hands with vigor
D) Notify the supervisor and risk management
The correct answer is C: Immediately wash the hands with vigor
15. As the nurse observes the student nurse during the administration of
a narcotic
analgesic IM injection, the nurse notes that the student begins to give the
medication
without frst aspirating. What should the nurse do?
A) Ask the student: "What did you forget to do?”
B) Stop. Tell me why aspiration is needed.
C) Loudly state: “You forgot to aspirate.”
D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”
The correct answer is D: Walk up and whisper in the student’s ear “Stop.
Aspirate. Then
inject.”
16. A client with Guillain Barre is in a non responsive state, yet vital signs
are stable and
breathing is independent. What should the nurse document to most
accurately describe
the client's condition?
A) Comatose, breathing unlabored
B) Glascow Coma Scale 8, respirations regular
C) Appears to be sleeping, vital signs stable
D) Glascow Coma Scale 13, no ventilator required
The correct answer is B: Glascow Coma Scale 8, respirations regular
17. A client enters the emergency department unconscious via
ambulance from theclient’s work place. What document should be given priority to guide the
direction of care
for this client?
A) The statement of client rights and the client self determination act
B) Orders written by the health care provider
C) A notarized original of advance directives brought in by the partner
D) The clinical pathway protocol of the agency and the emergency
department
The correct answer is C: A notarized original of advance directives
brought in by the
partner
18. The charge nurse has a health care team that consists of 1 PN, 1
unlicensed assistive
personnel (UAP) and 1 PN nursing student. Which assignment should be
questioned by
the nurse manager?
A) An admission at the change of shifts with atrial fbrillation and heart
failure - PN
B) Client who had a major stroke 6 days ago - PN nursing student
C) A child with burns who has packed cells and albumin IV running -
charge nurse
D) An elderly client who had a myocardial infarction a week ago - UAP
The correct answer is A: An admission at the change of shifts with atrial
fbrillation and
heart failure - PN
19. A mother brings her 3 month-old into the clinic, complaining that the
child seems to
be spitting up all the time and has a lot of gas. The nurse expects to fnd
which of the
following on the initial history and physical assessment?
A) Increased temperature and lethargy
B) Restlessness and increased mucus production
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor
The correct answer is B: Restlessness and increased mucus production
20. As the nurse takes a history of a 3 year-old with neuroblastoma, what
comments by
the parents require follow-up and are consistent with the diagnosis?
A) "The child has been listless and has lost weight."
B) "The urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her abdomen."
D) "We notice muscle weakness and some unsteadiness."
The correct answer is C: "Clothes are becoming tighter across her
abdomen."21. A 16 year-old enters the emergency department. The triage nurse
identifes that this
teenager is legally married and signs the consent form for treatment.
What would be the
appropriate action by the nurse?
A) Ask the teenager to wait until a parent or legal guardian can be
contacted
B) Withhold treatment until telephone consent can be obtained from the
partner
C) Refer the teenager to a community pediatric hospital emergency
department
D) Proceed with the triage process in the same manner as any adult client
The correct answer is D: Proceed with the triage process in the same
manner as any adult
client
22. A newly admitted elderly client is severely dehydrated. When planning
care for this
client, which task is appropriate to assign to an unlicensed assistive
personnel (UAP)?
A) Converse with the client to determine if the mucous membranes are
impaired
B) Report hourly outputs of less than 30 ml/hr
C) Monitor client's ability for movement in the bed
D) Check skin turgor every 4 hours
The correct answer is B: Report output of less than 30 ml/hr
23. The nurse has admitted a 4 year-old with the diagnosis of possible
rheumatic fever.
Which statement by the parent would cause the nurse to suspect an
association with this
disease?
A) Our child had chickenpox 6 months ago.
B) Strep throat went through all the children at the day care last month.
C) Both ears were infected over 3 months age.
D) Last week both feet had a fungal skin infection.
The correct answer is B: Strep throat went through all the children at the
day care last
month.
24. A nurse assigned to a manipulative client for 5 days becomes aware
of feelings for a
reluctance to interact with the client. The next action by the nurse should
be to
A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the client to avoid reinforcement of the
manipulative behaviorC) Confront the client about the negative effects of behaviors on other
clients and staff
D) Develop a behavior modifcation plan that will promote more functional
behavior
The correct answer is A: Discuss the feeling of reluctance with an
objective peer or
supervisor
25. A client is being treated for paranoid schizophrenia. When the client
became loud and
boisterous, the nurse immediately placed him in seclusion as a
precautionary measure.
The client willingly complied. The nurse’s action
A) May result in charges of unlawful seclusion and restraint
B) Leaves the nurse vulnerable for charges of assault and battery
C) Was appropriate in view of the client’s history of violence
D) Was necessary to maintain the therapeutic milieu of the unit
The correct answer is A: May result in charges of unlawful seclusion and
restraint
26. A client has been admitted to the Coronary Care Unit with a
myocardial infarction.
Which nursing diagnosis should have priority?
A) Pain related to ischemia
B) Risk for altered elimination: constipation
C) Risk for complication: dysrhythmias
D) Anxiety related to pain
The correct answer is A: Pain related to ischemia
27. The provisions of the law for the Americans with Disabilities Act
require nurse
managers to
A) Maintain an environment free from associated hazards
B) Provide reasonable accommodations for disabled individuals
C) Make all necessary accommodations for disabled individuals
D) Consider both mental and physical disabilities
The correct answer is B: Provide reasonable accommodations for disabled
individuals
28. A 42 year-old male client refuses to take propranolol hydrochloride
(Inderal) as
prescribed. Which client statement s from the assessment data is likely to
explain his
noncompliance?
A) "I have problems with diarrhea."
B) "I have difculty falling asleep."
C) "I have diminished sexual function."
D) "I often feel jittery."The correct answer is C: "I have diminished sexual function."
29. A school-aged child has had a long leg (hip to ankle) synthetic cast
applied 4 hours
ago. Which statement from the mother indicates that teaching has been
inadequate?
A) ”I will keep the cast for the next day uncovered to prevent burning of
the skin."
B) ”I can apply an ice pack over the area to relieve itching inside the
cast."
C) ”The cast should be propped on at least 2 pillows when my child is
lying down."
D) ”I think I remember that standing cannot be done until after 72 hours."
The correct answer is D: "I think I remember that standing cannot be done
until after 72
hours."
30. Which statement best describes time management strategies applied
to the role of a
nurse manager?
A) Schedule staff efciently to cover the needs on the managed unit
B) Assume a fair share of direct client care as a role model
C) Set daily goals with a prioritization of the work
D) Delegate tasks to reduce work load associated with direct care and
meetings
The correct answer is C: Set daily goals with a prioritization of the work
31. The pediatric clinic nurse examines a toddler with a tentative
diagnosis of
neuroblastoma. Findings observed by the nurse that is associated with
this problem
include which of these?
A) Lymphedema and nerve palsy
B) Hearing loss and ataxia
C) Headaches and vomiting
D) Abdominal mass and weakness
The correct answer is D: Abdominal mass and weakness
32. A 15 year-old client has been placed in a Milwaukee Brace. Which
statement from the
adolescent indicates the need for additional teaching?
A) "I will only have to wear this for 6 months."
B) "I should inspect my skin daily."
C) "The brace will be worn day and night."
D) "I can take it off when I shower."
The correct answer is A: "I will only have to wear this for 6 months."
33. The nurse manager has been using a decentralized block scheduling
plan to staff thenursing unit. However, staff have asked for many changes and exceptions
to the schedule
over the past few months. The manager considers self scheduling
knowing that this
method will
A) Improve the quality of care
B) Decrease staff turnover
C) Minimize the amount of overtime payouts
D) Improve team morale
The correct answer is D: Improve team morale
34. A client is admitted to the emergency room following an acute asthma
attack. Which
of the following assessments would be expected by the nurse?
A) Diffuse expiratory wheezing
B) Loose, productive cough
C) No relief from inhalant
D) Fever and chills
The correct answer is A: Diffuse expiratory wheezing
35. The nurse manager hears a health care provider loudly criticize one of
the staff nurses
within the hearing of others. The employee does not respond to the
health care provider's
complaints. The nurse manager's next action should be to
A) Walk up to the health care provider and quietly state: "Stop this
unacceptable
behavior."
B) Allow the staff nurse to handle this situation without interference
C) Notify the of the other administrative persons of a breech of
professional conduct
D) Request an immediate private meeting with the health care provider
and staff nurse
The correct answer is D: Request an immediate private meeting with the
health care
provider and staff nurse
36. A client is admitted to a voluntary hospital mental health unit due to
suicidal ideation.
The client has been on the unit for 2 days and now states “I demand to be
released now!”
The appropriate action is for the nurse to
A) You cannot be released because you are still suicidal.
B) You can be released only if you sign a no suicide contract.
C) Let’s discuss your decision to leave and then we can prepare you for
discharge.D) You have a right to sign out as soon as we get an order from the health
care provider's
discharge order.
The correct answer is C: Let’s discuss your decision to leave and then we
can prepare you
for discharge.
37. A client is admitted with infective endocarditis (IE). Which symptom
would alert the
nurse to a complication of this condition?
A) Dyspnea
B) Heart murmur
C) Macular rash
D) Hemorrhage
The correct answer is B: Heart murmur Large, soft, rapidly developing
vegetations attach
to the heart valves.
38. A nurse admits a premature infant who has respiratory distress
syndrome. In planning
care, nursing actions are based on the fact that the most likely cause of
this problem
stems from the infant's inability
to
A) Stabilize thermoregulation
B) Maintain alveolar surface tension
C) Begin normal pulmonary blood flow
D) Regulate intra cardiac pressure
The correct answer is B: Maintain alveolar surface tension
39. An 18 year-old client is admitted to intensive care from the
emergency room
following a diving accident. The injury is suspected to be at the level of
the 2nd cervical
vertebrae. The nurse's priority
assessment should be
A) Response to stimuli
B) Bladder control
C) Respiratory function
D) Muscle weakness
The correct answer is C: Respiratory function
40. The nurse is caring for a client who was successfully resuscitated from
a pulseless
dysrhythmia. Which of the following assessments is CRITICAL for the
nurse to include
in the plan of care?
A) Hourly urine outputB) White blood count
C) Blood glucose every 4 hours
D) Temperature every 2 hours
The correct answer is A: Hourly urine output
41. The charge nurse on the night shift at an urgent care center has to
deal with admitting
clients of a higher acuity than usual because of a large fre in the area.
Which style of
leadership and decision-making would be best in this circumstance?
A) Assume a decision-making role
B) Seek input from staff
C) Use a non-directive approach
D) Shared decision-making with others
The correct answer is A: Assume a decision making role
42. The nurse admitting a 5 month-old who vomited 9 times in the past 6
hours should
observe for signs of which overall imbalance?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Some increase in the serum hemoglobin
D) A little decrease in the serum potassium
The correct answer is B: Metabolic alkalosis
43. Which activity can the RN ask an unlicensed assistive personnel (UAP)
to perform?
A) Take a history on a newly admitted client
B) Adjust the rate of a gastric tube feeding
C) Check the blood pressure of a 2 hours post operative client
D) Check on a client receiving chemotherapy
The correct answer is C: Check the blood pressure of a 2 hours post
operative client
44. A child is injured on the school playground and appears to have a
fractured leg. The
frst action the school nurse should take is
A) Call for emergency transport to the hospital
B) Immobilize the limb and joints above and below the injury
C) Assess the child and the extent of the injury
D) Apply cold compresses to the injured area
The correct answer is C: Assess the child and the extent of the injury
45. When interviewing the parents of a child with asthma, it is most
important to gather
what information about the child's environment?
A) Household pets
B) New furniture
C) Lead based paintD) Plants such as cactus
The correct answer is A: Household pets
46. An 80 year-old client admitted with a diagnosis of possible cerebral
vascular accident
has had a blood pressure from 180/110 to 160/100 over the past 2 hours.
The nurse has
also noted increased lethargy. Which assessment fnding should the nurse
report
immediately to the health care provider?
A) Slurred speech
B) Incontinence
C) Muscle weakness
D) Rapid pulse
The correct answer is A: Slurred speech
47. A 3 year-old child is brought to the clinic by his grandmother to be
seen for
"scratching his bottom and wetting the bed at night." Based on these
complaints, the
nurse would initially assess for which problem?
A) Allergies
B) Scabies
C) Regression
D) Pinworms
The correct answer is D: Pinworms
48. A 72 year-old client with osteomyelitis requires a 6 week course of
intravenous
antibiotics. In planning for home care, what is the most important action
by the nurse?
A) Investigating the client's insurance coverage for home IV antibiotic
therapy
B) Determining if there are adequate hand washing facilities in the home
C) Assessing the client's ability to participate in self care and/or the
reliability of a
caregiver
D) Selecting the appropriate venous access device
The correct answer is C: Assessing the client''s ability to participate in self
care and/or the
reliability of a caregiver
49. The mother of a child with a neural tube defect asks the nurse what
she can do to
decrease the chances of having another baby with a neural tube defect.
What is the best
response by the nurse?
A) "Folic acid should be taken before and after conception."B) "Multivitamin supplements are recommended during pregnancy."
C) "A well balanced diet promotes normal fetal development."
D) "Increased dietary iron improves the health of mother and fetus."
The correct answer is A: "Folic acid should be taken before and after
conception."
50. A PN is assigned to care for a newborn with a neural tube defect.
Which dressing if
applied by the PN would need no further intervention by the charge
nurse?
A) Telfa dressing with antibiotic ointment
B) Moist sterile non adherent dressing
C) Dry sterile dressing that is occlusive
D) Sterile occlusive pressure dressing
The correct answer is B: Moist sterile non adherent dressing
51. A nurse is providing a parenting class to individuals living in a
community of older
homes. In discussing formula preparation, which of the following is most
important to
prevent lead poisoning?
A) Use ready-to-feed commercial infant formula
B) Boil the tap water for 10 minutes prior to preparing the formula
C) Let tap water run for 2 minutes before adding to concentrate
D) Buy bottled water labeled "lead free" to mix the formula
The correct answer is C: Let tap water run for 2 minutes before adding to
concentrate
52. A client is admitted to the rehabilitation unit following a CVA and mild
dysphagia.
The most appropriate intervention for this client is
A) Position client in upright position while eating
B) Place client on a clear liquid diet
C) Tilt head back to facilitate swallowing reflex
D) Offer fnger foods such as crackers or pretzels
The correct answer is A: Position client in upright position while eating
53. The nurse explains an autograft to a client scheduled for excision of a
skin tumor. The
nurse knows the client understands the procedure when the client says, "I
will receive
tissue from…
A) a tissue bank."
B) a pig."
C) my thigh."
D) synthetic skin."
The correct answer is C: my thigh."54. The nurse is caring for a newborn with tracheoesophageal fstula.
Which nursing
diagnosis is a priority?
A) Risk for dehydration
B) Ineffective airway clearance
C) Altered nutrition
D) Risk for injury
The correct answer is B: Ineffective airway clearance
55. A client has been hospitalized after an automobile accident. A full leg
cast was
applied in the emergency room. The most important reason for the nurse
to elevate the
casted leg is to
A) Promote the client's comfort
B) Reduce the drying time
C) Decrease irritation to the skin
D) Improve venous return
The correct answer is D: Improve venous return
56. During the initial home visit a nurse is discussing the care of a newly
diagnosed client
with Alzheimer's disease with family members. Which of these
interventions would be
most helpful at this time?
A) Leave a book about relaxation techniques
B) Write out a daily exercise routine for them to assist the client to do
C) List actions to improve the client's daily nutritional intake
D) Suggest communication strategies
The correct answer is D: Suggest communication strategies
57. The nurse is teaching a client with non-insulin dependent diabetes
mellitus about the
prescribed diet. The nurse should teach the client to
A) Maintain previous calorie intake
B) Keep a candy bar available at all times
C) Reduce carbohydrates intake to 25% of total calories
D) Keep a regular schedule of meals and snacks
The correct answer is D: Keep a regular schedule of meals and snacks
58. The mother of a 2 month-old baby calls the nurse 2 days after the frst
DTaP, IPV,
Hepatitis B and HIB immunizations. She reports that the baby feels very
warm, cries
inconsolably for as long as 3 hours, and has had several shaking spells. In
addition to
referring her to the emergency room, the nurse should document the
reaction on thebaby's record and expect which immunization to be
most associated to the fndings in the infant?
A) DTaP
B) Hepatitis B
C) Polio
D) H. Influenza
The correct answer is A: DTaP
59. The nurse is teaching a class on HIV prevention. Which of the
following should be
emphasized as increasing risk?
A) Donating blood
B) Using public bathrooms
C) Unprotected sex
D) Touching a person with AIDS
The correct answer is C: Unprotected sex
60. The charge nurse is planning assignments on a medical unit. Which
client should be
assigned to the unlicensed assistive personnel (UAP)? A client with
A) Difculty swallowing after a mild stroke
B) an order of enemas until clear prior to colonoscopy
C) an order for a post-op abdominal dressing change
D) transfer orders to a long term facility
The correct answer is B: an order of enemas until clear prior to
colonoscopy
61. A 6 year-old child is seen for the frst time in the clinic. Upon
assessment, the nurse
fnds that the child has deformities of the joints, limbs, and fngers,
thinned upper lip, and
small teeth with faulty enamel. The mother states: ”My child seems to
have problems in
learning to count and recognizing basic colors.” Based on this data, the
nurse suspects
that the child is most likely showing the effects of which problem?
A) Congenital abnormalities
B) Chronic toxoplasmosis
C) Fetal alcohol syndrome
D) Lead poisoning
The correct answer is C: Fetal alcohol syndrome
62. The nurse has performed the initial assessments of 4 clients admitted
with an acute
episode of asthma. Which assessment fnding would cause the nurse to
call the health
care provider immediately?
A) Prolonged inspiration with each breathB) Expiratory wheezes that are suddenly absent in 1 lobe
C) Expectoration of large amounts of purulent mucous
D) Appearance of the use of abdominal muscles for breathing
The correct answer is B: Expiratory wheezes that are suddenly absent in
one lobe
63. The nurse is planning a meal plan that would provide the most iron for
a child with
anemia. Which dinner menu would be best?
A) Fish sticks, french fries, banana, cookies, milk
B) Ground beef patty, lima beans, wheat roll, raisins, milk
C) Chicken nuggets, macaroni, peas, cantaloupe, milk
D) Peanut butter and jelly sandwich, apple slices, milk
The correct answer is B: Ground beef patty, lima beans, wheat roll,
raisins, milk
64. A 10 year-old client is recovering from a splenectomy following a
traumatic injury.
The clients laboratory results show a hemoglobin of 9 g/dL and a
hematocrit of 28
percent. The best approach for the nurse to use is to
A) Limit milk and milk products
B) Encourage bed activities and games
C) Plan nursing care around lengthy rest periods
D) Promote a diet rich in iron
The correct answer is C: Plan nursing care around lengthy rest periods
65. The nurse planning care for a 12 year-old child with sickle cell disease
in a vasoocclusive
crisis of the elbow should include which one of the following as a priority?
A) Limit fluids
B) Client controlled analgesia
C) Cold compresses to elbow
D) Passive range of motion exercise
The correct answer is B: Client controlled analgesia
66. As the nurse provides discharge teaching to the parents of a 15
month-old child with
Kawasaki disease. The child has received immunoglobulin therapy. Which
instruction
would be appropriate?
A) High doses of aspirin will be continued for some time
B) Complete recovery is expected within several days
C) Active range of motion exercises should be done frequently
D) The measles, mumps and rubella vaccine should be delayed
The correct answer is D: The measles, mumps and rubella vaccine should
be delayed67. The nurse is giving instructions to the parents of a child with cystic
fbrosis. The
nurse would emphasize that pancreatic enzymes should be taken
A) Once each day
B) 3 times daily after meals
C) With each meal or snack
D) Each time carbohydrates are eaten
The correct answer is C: With each meal or snack
68. The nurse is assessing an 8 month-old infant with a malfunctioning
ventriculoperitoneal shunt. Which one of the following manifestations
would the infant
be most likely to exhibit?
A) Lethargy
B) Irritability
C) Negative Moro
D) Depressed fontanel
The correct answer is B: Irritability
69. The nurse is performing a physical assessment on a toddler. Which of
the following
should be the frst action?
A) Perform traumatic procedures
B) Use minimal physical contact
C) Proceed from head to toe
D) Explain the exam in detail
The correct answer is B: Use minimal physical contact
70. A client has been tentatively diagnosed with Graves' disease
(hyperthyroidism).
Which of these fndings noted on the initial nursing assessment requires
quick
intervention by the nurse?
A) A report of 10 pounds weight loss in the last month
B) A comment by the client "I just can't sit still."
C) The appearance of eyeballs that appear to "pop" out of the client's eye
sockets
D) A report of the sudden onset of irritability in the past 2 weeks
The correct answer is C: The appearance of eyeballs that appear to "pop"
out of the
client''s eye sockets
71. Which serum blood fndings with diabetic ketoacidosis alerts the nurse
that
immediate action is required?
A) pH below 7.3
B) Potassium of 5.0
C) HCT of 60D) Pa O2 of 79%
The correct answer is C: HCT of 60
72. The nurse is preparing the teaching plan for a group of parents about
risks to toddlers.
The nurse plans to explain proper communication in the event of
accidental poisoning.
The nurse should plan to tell the parents to frst state what substance was
ingested and
then what information should be the priority for the parents to
communicate?
A) The parents' name and telephone number
B) The currency of the immunization and allergy history of the child
C) The estimated time of the accidental poisoning and a confrmation that
the parents will
bring the containers of the ingested substance
D) The affected child's age and weight
The correct answer is D: The affected child''s age and weight
73. A 2 year-old child is brought to the health care provider's ofce with a
chief
complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse
should include
which statement?
A) Place the child on clear liquids and gelatin for 24 hours
B) Continue with the regular diet and include oral rehydration fluids
C) Give bananas, apples, rice and toast as tolerated
D) Place NPO for 24 hours, then rehydrate with milk and water
The correct answer is B: Continue with the regular diet and include oral
rehydration
fluids
74. The nurse is teaching an elderly client how to use MDI's (multi-dose
inhalers). The
nurse is concerned that the client is unable to coordinate the release of
the medication
with the inhalation phase. What is the nurse's best recommendation to
improve delivery
of the medication?
A) Nebulized treatments for home care
B) Adding a spacer device to the MDI canister
C) Asking a family member to assist the client with the MDI
D) Request a visiting nurse to follow the client at home
The correct answer is B: Adding a spacer device to the MDI canister
75. Which of the following manifestations observed by the school nurse
confrms the
presence of pediculosis capitis in students?A) Scratching the head more than usual
B) Flakes evident on a student's shoulders
C) Oval pattern occipital hair loss
D) Whitish oval specks sticking to the hair
The correct answer is D: Whitish oval specks sticking to the hair
76. When parents call the emergency room to report that a toddler has
swallowed drain
cleaner, the nurse instructs them to call for emergency transport to the
hospital. While
waiting for an ambulance,
the nurse would suggest for the parents to give sips of which substance?
A) Tea
B) Water
C) Milk
D) Soda
The correct answer is B: Water
77. A client is scheduled for an IVP (Intravenous Pyelogram). Which of the
following
data from the client’s history indicate a potential hazard for this test?
A) Reflex incontinence
B) Allergic to shellfsh
C) Claustrophobia
D) Hypertension
The correct answer is B: Allergic to shellfsh
78. The nurse is preparing a handout on infant feeding to be distributed to
families
visiting the clinic. Which notation should be included in the teaching
materials?
A) Solid foods are introduced 1 at a time beginning with cereal
B) Finely ground meat should be started early to provide iron
C) Egg white is added early to increase protein intake
D) Solid foods should be mixed with formula in a bottle
The correct answer is A: Solid foods are introduced 1 at a time beginning
with cereal
79. The nurse is caring for a client with sickle cell disease who is
scheduled to receive a
unit of packed red blood cells. Which of the following is an appropriate
action for the
nurse when administering
the infusion?
A) Storing the packed red cells in the medicine refrigerator while starting
IV
B) Slow the rate of infusion if the client develops fever or chills
C) Limit the infusion time of each of the unit to a maximum of 4 hoursD) Assess vital signs every 15 minutes throughout the entire infusion
The correct answer is C: Limit the infusion time of each of the unit to a
maximum of
four hours
80. A client with a documented pulmonary embolism has the following
arterial blood
gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 -
22. Based
on this data, what is the frst nursing action?
A) Review other lab data
B) Notify the health care provider
C) Administer oxygen
D) Calm the client
The correct answer is C: Administer oxygen
81. A client diagnosed with hepatitis C discusses his health history with
the admitting
nurse. The nurse should recognize which statement by the client as the
most important?
A) I got back from Central America a few weeks ago.
B) I had the best raw oysters last week.
C) I have many different sex partners.
D) I had a blood transfusion 15 years ago.
The correct answer is D: I had a blood transfusion
82. A client is recovering from a thyroidectomy. While monitoring the
client's initial post
operative condition, which of the following should the nurse report
immediately?
A) Tetany and paresthesia
B) Mild stridor and hoarseness
C) Irritability and insomnia
D) Headache and nausea
The correct answer is A: Tetany and paresthesia
83. A client is admitted with a right upper lobe infltrate and to rule out
tuberculosis. The
most appropriate action by the nurse to protect the self would be which of
these?
A) Negative room ventilation
B) Face mask with sheild
C) Particulate respirator mask
D) Airborne precautions
The correct answer is C: Particulate respirator mask
84. A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be
essential for
the nurse to include at the change of shift report?A) The client lost 2 pounds in 24 hours
B) The client’s potassium level is 4 mEq/liter.
C) The client’s urine output was 1500 cc in 5 hours
D) The client is to receive another dose of Lasix at 10 PM
The correct answer is C: The client’s urine output was 1500 cc in fve
hours
85. The nurse is caring for a client with a colostomy. During a teaching
session, the nurse
recommends that the pouch be emptied
A) When it is 1/3 to 1/2 full
B) Prior to meals
C) After each fecal elimination
D) At the same time each day
The correct answer is A: When it is 1/3 to 1/2 full
86. Lactulose (Chronulac) has been prescribed for a client with advanced
liver disease.
Which of the following assessments would the nurse use to evaluate the
effectiveness of
this treatment?
A) An increase in appetite
B) A decrease in fluid retention
C) A decrease in lethargy
D) A reduction in jaundice
The correct answer is C: A decrease in lethargy
87. The mother of a 3 month-old infant tells the nurse that she wants to
change from
formula to whole milk and add cereal and meats to the diet. What should
be emphasized
as the nurse teaches about infant nutrition?
A) Solid foods should be introduced at 3-4 months
B) Whole milk is difcult for a young infant to digest
C) Fluoridated tap water should be used to dilute milk
D) Supplemental apple juice can be used between feedings
The correct answer is B: Whole milk is difcult for a young infant to digest
88. The nurse is assessing a 55 year-old female client who is scheduled
for abdominal
surgery. Which of the following information would indicate that the client
is at risk for
thrombus formation in the post-operative period?
A) Estrogen replacement therapy
B) 10% less than ideal body weight
C) Hypersensitivity to heparin
D) History of hepatitis
The correct answer is A: Estrogen replacement therapy89. The nurse is planning discharge for a 90 year-old client with
musculoskeletal
weakness. Which intervention should be included in the plan and would
be most effective
for the prevention of falls?
A) Place nightlight in the bedroom
B) Wear eyeglasses at all times
C) Install grab bars in the bathroom
D) Teach muscle strengthening exercises
The correct answer is A: Place nightlight in the bedroom
90. An 8 year-old client is admitted to the hospital for surgery. The child’s
parent reports
the following allergies. Of these allergies which one should all health care
personnel be
aware of?
A) Shellfsh
B) Molds
C) Balloons
D) Perfumed soap
The correct answer is C: Balloons
91. The nurse is caring for a client who is post-op following a thoracotomy.
The client
has 2 chest tubes in place, connected to 1 chest drain. The nursing
assessment reveals
bubbling in the water
seal chamber when the client coughs. What is the most appropriate
nursing action?
A) Clamp the chest tube
B) Call the surgeon immediately
C) Continue to monitor the client to see if the bubbling increases
D) Instruct the client to try to avoid coughing
The correct answer is C: Continue to monitor the client to see if the
bubbling increases
92. The nurse is reinforcing teaching to a 24 year-old woman receiving
acyclovir
(Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these
instructions should
the nurse give the client?
A) Complete the entire course of the medication for an effective cure
B) Begin treatment with acyclovir at the onset of symptoms of recurrence
C) Stop treatment if she thinks she may be pregnant to prevent birth
defects
D) Continue to take prophylactic doses for at least 5 years after the
diagnosisThe correct answer is B: Begin treatment with acyclovir at the onset of
symptoms of
recurrence
93. An 8 year-old child is hospitalized during the edema phase of minimal
change
nephrotic syndrome. The nurse is assisting in choosing the lunch menu.
Which menu is
the best choice?
A) Bologna sandwich, pudding, milk
B) Frankfurter, baked potato, milk
C) Chicken strips, corn on the cob, milk
D) Grilled cheese sandwich, apple, milk
The correct answer is C: Chicken strips, corn on the cob, milk [Show Less]