EXIT EXAM 2022 Medical Surgical Advanced

HESI EXIT EXAM 2022/20231. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? A. WBC count 8,000/mm3.B. Platelets 150,000/mm3.C. Aspartate aminotransferase 10 units/L.D. E rythrocyte sedimentation rate 75 mm/hr2. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? A. Platelet count.B. Potassium level.C. Creatine clearance.D. Prealbumin.3. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?A. Place an ice pack over the cast.B. P alpate the pulse distal to the cast.C. Teach the client to keep the cast clean and dry.D. Position the casted extremity on a pillow.4. A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply)A. Keep objects in the client’s room in the same place. B. Ensure there is high-wattage lighting in the client’sroom. C . Approach the client from the side.D. Allow extra time for the client to perform tasks. E . Touch the client gently to announce presence.5. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions
about the disease. To research the nurse should identify that which of the following electronicdatabase has the most comprehensive collection of nursing (Unable to read) articles?A. MEDLINEB. C INAHL.C. ProQuest.D. Health Source.6. A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following should actions should the nurse take first?A. Obtain a baseline ECG.B. Obtain a blood specimen for ABG analysis.C. Insert an 18-gauge IV catheter.D. A dminister 100% humidified oxygen.7. A nurse is planning care for a client who has unilateral paralysis and dysphagia following aright hemispheric stroke. Which of the following interventions should the nurse include in the plan?A. Place food on the left side of the client’s mouth when he is ready to eat.B. Provide total care in performing the client’s ADLs.C. Maintain the client on bed rest.D. P lace the client’s left arm on a pillow while he is sitting.8. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take?A. . Confront the client about this behavior.B. Express sympathy for the client’s situation.C. Speak assertively to the client.D. Stand within 30 cm (1 ft) of the client when speaking with them.9. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take?
A. Cleanse equipment before removal from the client’s room.B. L imit the client’s visitors to 30 min per day.C. Discard the client’s linens in a double bag. D. Discard the radioactive source in a biohazard bag10. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfateintravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity.Which of the following actions should the nurse take?a. Position the client supineb. Prepare an IV bolus of dextrose 5% in waterc. Administer methylergonovine IMd. Administer calcium gluconate IV11. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?a. Experiencing delusionsb. Male genderd. A history of being in prison12. A nurse is preparing to perform a sterile dressing change. Which of the following actionsshould the nurse take when setting up the sterile field?a. Place the cap from the solution sterile side up on clean surfaceb. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body’s firstc. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm(1-inch) border around any sterile drape or wrap that is considered contaminated.d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; shouldbe ABOVE waist level13. A nurse is providing teaching to an older adult client about methods to promote nighttimesleep. Which of the following instructions should the nurse include?a. Eat a light snack before bedtimeb. Stay in bed at least 1 hr if unable to fall asleepc. Take a 1 hr nap during the dayc. Previous violent behavior
d. Perform exercises prior to bedtime14. A home health nurse is preparing for an initial visit with an older adult client who livesalone. Which of the following actions should the nurse take first?a. Educate the client about current medical diagnosisb. Refer the client to a meal delivery programc. Identify environmental hazards in the home
c. The client is showing evidence of phenytoin toxicityd. Arrange for client transportation to follow-up appointments Rationale Priority: Assess first.15. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client?a. “Can you tell me who visited you today?”b. “What high school did you graduate fromc. “Can you list your current medications?”d. “What did you have for breakfast yesterday?”16. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teachinga. HbA1c level greater than 8%- 6.5 – 8 is the target reference. >b. Blood glucose level greater than 200 mg/dL at bedtimec. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC d.HbA1c level less than 7%17. A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurseconclude if the client develops ataxia and incoordination?a. The client is experiencing an adverse reaction to rifampinb. The client’s seizure disorder is no longer under controlc. The client is having adverse effects due to combination antimicrobial therapy18. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?a. Increase in frequency of swallowing→ may indicate bleedingb. Moderate sanguineous drainage on the drip padc. Bruising to the face→ side effectd. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative) Rationale “Requires immediate action” choose the worst possibility that could lead to. ABC19. A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?a. Give scheduled doses of acetaminophen every 6 hr b. Monitor the child’s cardiac statusc. Administer antibiotics via intermittent IV bolus for 24 hrd. Provide stimulation with children of the same age in the playroom

20. A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco?a. Use of tobacco might lead to alcohol and drug abuseb. Smoking in adolescence increases the risk of developing lung cancer later in life c. Use of tobacco decreases the level of athletic abilityd. Smoking in adolescence increases the risk of lifelong addiction21. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?a. Total bilirubinb. Urine ketonesc. Serum potassium- diuretic that retains potassium= hyperkalemic riskd. Platelet count22. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role?a. “I will let the client know that I am available as the interpreter.”b. “I will receive a small fee for interpreting for this client.”c. “I am glad I’m available today, but when I’m not, you can use a family member.”d. “I will let the client know that an interpreter is unavailable during the night shift.”23.A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year- old. Which of the following actions should the nurse take?a.(Unable to read)b.Tell the child they will feel discomfort during the catheter insertion.c.Use a mummy restraint to hold the child during the catheter insertion.d.Require the parents to leave the room during the procedure.24.A nurse is caring for a client who has arteriovenous fistula which of the following findings should the nurse report?a.Thrill upon palpation.b.Absence of a bruit.c.Distended blood vesselsd.Swishing sound upon auscultation.25.A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching?
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a.“I will soak in the tub rather and showering”b.“I will wear loose clothing around my ICD”c.“I will stop using my microwave oven at home because of my ICD”d.“I can hold my cellphone on the same side of my body as the ICD”26.A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nursemake?a.“Describe your feelings to me about being pregnant”b.“You should discuss your feelings about being pregnant with your provider”c.“Have you discussed these feelings with your partner?”d.“When did you start having these feelings?”27.A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?a.Encourage a maximum fluid intake of 1,500 ml per day.b.Increase the amount of refined grains in the client’s diet.c.Provide the client with a cold drink prior to defecation.d.Administer a rectal suppository 30 minutes prior to scheduled defecation times.28. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of thefollowing statements by the client indicates the need for a referral to physical therapy?A. “I have been experiencing more tremors in my left arm than before”B. “I noticed that I am having a harder time holding on to my toothbrush”C. “ Lately, I feel like my feet are freezing up, as they are stuck to the ground”D. “Sometimes, I feel I am making a chewing motion when I’m not eating”29. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the followingfindings should the nurse expect? A. Increased creatine.B. Increased hemoglobin.C. Increased bicarbonate.D. Increased calcium.30. A nurse is administering a scheduled medication to a client. The client reports that the medication appearsdifferent than what they take at home. Which of the following responses should the nurse take?A. “Did the doctor discuss with you that there was a change in this medication?”
B. “I recommend that you take this medication as prescribed”C. “Do you know why this medication is being prescribed to you?”D. “ I will call the pharmacist now to check on this medication”31. A charge nurse is recommending postpartum client discharge following a local disaster. Which ofthe following should the nurse recommend for discharge?A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg.B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago.C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage.D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration.32. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. Which to report?a. Herpes simplex.b. Human papillomavirusc. Candidiasisd. C hlamydia

33. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral toa dietitianA. A client who has a prescription for warfarin and states “I will need to limit how much spinach I eat”.B. A client who has gout and states, “I can continue to eat anchovies on my pizza.”C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that containpotassium”.D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glassof water”.34. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nursetake?A . Place the tip of the thermometer under the center of the infant’s axilla. B . Pull the pinna of the infant’s ear forward before inserting the probe.B. Insert the probe 3.8 cm (1.5in) into the infant’s rectum.C. Insert the thermometer in front of the infant’s tongue.35. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which ofthe following information should the nurse include?A. . Children who have varicella are contagious until vesicles are crusted.B. . Children who have varicella should receive the herpes zoster vaccination. C . Children who have varicella should be placed in droplet precaution. D. Children who have varicella are contagious 4 days before the first vesicle eruption.36. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the providershould the nurse expect?A. Withhold the next dose.B. Increase the dosage.C. Discontinue the medication.D. A dminister the medication.
34. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of thefollowing medications should the nurse administer?A.PregabalinB.LorazepamC.ColchicinD. Codeine.38. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the followingactions should the nurse take?A . Prime IV tubing with 0.9% sodium chloride.B. Use a 24-gauge IV catheterC. Obtain filter less IV tubing.D. Place blood in the warmer for 1 hr.39. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the followingshould the toddler participate?A. Looking at alphabet flashcards.B. P laying with a large plastic truck.C. Use scissors cut out paper shapes.D. Watching a cartoon in the dayroom.40. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendationsshould the nurse make?A. Coffee with creamer.B. Lettuce with sliced avocados.C. B roiled skinless chicken breast with brown rice.
    D. Warm toast with margarine.41.A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take?a.Administer ondansetron.b.Place the client in a warm shower.c.Apply fundal pressure during contractions.d.Assist the client to a supine position.42.A nurse in an emergency department is performing triage for multiple clients followinga disaster in the community. To which of the following types of injuries should the nurse assign the highest priority?a.Below-the knee amputationb.Fractured tibiac.95% full-thickness body burnd.10cm (4in) laceration to the forearm43.A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include?a.Remove the client’s restraint every 4hrb. Document the client’s condition every 15 minc.Attach the restrain to the bed’s side railsd.Request a PRN restrain prescription for clients who are aggressive44.A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader?a.Acts as an advocate for the nursing unit.b.(Unable to read) for the unitc.Priorities staff request over client needs.d.Provides routine client care and documentation.45.A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that she has been following her (unable to read) care. The nurse should identify which of the following findings indicates a need to revise the client’s plan of care.a.Serum sodium 144 mEq/b.(Unable to read)c.Hba1c 10 %d.Random serum glucose 190 mg/dl.
    a. Level of consciousness. (priority)- decreased LOC can mean less o2 going tothe brain ?46. A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurseis appropriate?b. You must use a breast pump to provide breast milk.c. You must use nipple shield when breastfeeding.d. You may breastfeed after your baby develops his antibiotics.47. A nurse is caring for a client who has returned to the medical-surgical unit following atransurethral resection of the prostate. Which of the following should the nurse identify aspriority nursing assessment after reviewing the clients information? Exhibit.b. Skin turgord. Bowel sounds48. A nurse is caring for a client who has hyperthermia .Which of the following actions forthe nurse to take?a. Submerge the adolescent feet in ice waterb. Cover the adolescent with a thermal blanket → if hypothermia.c. Administer oral acetaminophen49. A nurse manager is updating protocols for belt restraints. Which of the following guidelinesshould the nurse include?b. Attach the restraints to the beds side railsc. Request a PRN restraints prescription for clients who are aggressived. Remove the client restraints every 4 hours50. A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client’s airway, which of the following is the nurse’s priority intervention?a. Providing pain managementb. Offering emotional supportc. Preventing infectiona. You may breastfeed unless your nipples are cracked or bleeding.c. Deep-tendon reflexesd. Initiate seizure precautionsa. Document the client’s conditions every 15 minutesd. Initiating IV fluid resuscitation – they are at risk for hypovolemic shock d/t 3rdspacing
    B.C.Let’s talk about your mom’s cancer and how things will progress from here.Tell me how you are feeling about your mom dying.51. A nurse is caring for a client who has cancer and is being transferred to hospice care.The client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks meabout dying.” which of the following responses by the nurse is appropriate? (SATA)A. Hospice will take good care of your mom, so I wouldn’t worry about that.D. Tell her not to worry. She still has plenty of time left.52. A nurse is reviewing the medical records of four clients. The nurse should identify that whichof the following client findings follow up care?a. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal)b. A client who is scheduled for colonoscopy and taking sodium phosphated. A client who is taking warfarin and has INR of 1.8 (normal if taking warfarin)53. A community health nurse receives a referral for a family home visit. Which of the followingtasks should the nurse perform first?b. Implement the nursing processc. Schedule a time for the home visitd. Contact the family by phone54. A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make?b. Your partner can be a great source of support for you at this timec. Is there a reason you don’t want your partner to know about your procedure?d. The provider will be tactful when talking to your partner55. A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb)from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage?b. 15%c. 8.1%d. 13.3%56. A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate.Which of the following interventions should the nurse implement?E. You sound like you have questions about your mom dying. Let’s talk about it.c. A client who received a Mantoux test 48 hours ago and has indurationa. Clarify the source of the referralYou have the right to decide who receives information -a.a. 7.5%
    a. Perform fundal massage (massage if fundus is boggy)c. Insert an indwelling urinary catheter.d. Apply cold therapy to the client’s perineal area.( warm)57. A nurse is providing discharge teaching to a client who has cancer and a prescription for afentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching?b. Apply patch to your forearmc. Avoid high-fiber foods while taking this medicationd. Remove the patch for 8 hours every day to reduce the risk for tolerance.58. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?a. We should discuss resources to implement in your daily lifeb. Let me show you simple relaxation exercises to manage stress.c. Let’s talk about how you can change your response to stress59. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication?a. Avocadosc. Pepperoni pizzad. Smoked salmon 60. A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report?A. (Unable to read)B. (Unable to read)C. A nswer might be lower platelets.D. (Unable to read)61. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include?A. Use the client’s children to provide interpretation.B. ( Answer was the nurse was going to do the interpretation) b. Pour water from a squeeze bottle over the client’s perineal area.a. Avoid hot tub while wearing the patchd. We should establish our roles in the initial session.b. Whole grain bread
    C. Offer client’s translation services for a nominal fee.D. Evaluate the clients’ understanding at regular intervals.62.A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?a.“I can give you information about respite care if you are interested.”b.“You should consider taking a sleeping pill before bed each night”c.“It must be difficult taking care of someone who is terminally ill”d.“You are doing a great job taking care of your mother”63.A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child’s glucose. The nurse should identify this finding as an adverse effect of which of the following medicationsa.Methylprednisolone.b.Ondansetron.c.Guaifenesin.d.Amoxicillin.64.The nurse is providing teaching about folic acid to a client who is primagravida. Which of the following information should the nurse include in theteaching?a.“You should take folic acid to decrease the risk of transmitting infections to your baby”b.“You should consume a maximum of 300 micrograms of folic acid every day”.c.“You can increase your dietary intake of folic acid by eating cereals and citrus fruits”.d.“You can expect your urine to appear red-tingled while taking folic acid supplements”.65.A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse’s priority?a.Social relationship with peers.b.Plans for attending school while pregnant.c.(Unable to read) (Picked this one) Medicaid?d.Understanding of infant care.66.A nurse manager is planning to teach staff about critical pathways.
    Which of the following information should the nurse include?a.Critical pathways have unlimited timeframe for completionb.(Unable to read) decrease health care costs.c.(Unable to read) critical pathway if variances (Unable to read)d.(Unable to read) are used to create the critical pathway.67.A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following should the nurse report to the provider?Exhibit 1Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature: 37.4C (99.3F)Exhibit 2Medication Administration Record Clozapine 150 mg PO twice dailyBenztropine 0.5 mg PO twice daily as needed for tremors. Exhibit 3Nurse’s notes:Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous.a.Dietary intakeb.Heart rate.c.Sore throat.d.Blood pressure.
    68.A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnela.“The nurse is legally responsible for the actions of the AP”.b.“An AP can perform tasks outside of his range if he has been trained”.c.“An experienced AP can delegate to another AP”.d.“An RN evaluates the client needs to determine tasks to delegate”69.A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?A. Contractions lasting 80 seconds B. FHR baseline 170/minC.Early decelerations in the FHRD.Temperature 37.4C (99.3)70.A nurse working in a rehabilitation facility is developing a discharge plan for aclient who has left-sided hemiplegia the following actions is the nurse’s priority?a.Consult with a case manager about insurance coverage.b.Counsel caregivers about respite care options.c.Ensure that the client has a referral for physical therapy.d.Refer the client to a local stroke support group.71.A nurse in a mental health unit is planning room assignments for four clients.Which of the following client should be closest to the nurse’s station?a.A client who has an anxiety disorder and is experiencing moderate anxiety.b.A client who has somatic symptom disorder and reports chronic pain.c.A client who has depressive disorder and reports feeling hopeless.d.A client who has bipolar disorder and impaired social interactions.72.A nurse is preparing to measure a temperature of an infant. Which of thefollowing action should the nurse take?a.Place the tip of the thermometer under the center of the infant’s axilla.b.Pull the pinna of the infant’s ear forward before inserting the probe.c.Insert the probe 3.8 cm (1.5in) into the infant’s rectum.d.Insert the thermometer in front of the infant’s tongue.
    73.A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?a.Encourage the client to spend time in the day roomb.Withdraw the client’s TV privileges is the does not attend group therapyc.Encourage the client to take frequent rest periodsd.Place the cline in seclusion when he exhibits signs of anxiety74.A nurse is admitting medications to a group of clients. Which of the following occurrences requires the completion of an incident report?a.A client receives his antibiotics 2hr lateb.A client vomits within 20min of taking his morning medicationsc.A client requests his statin to be administered at 2100d.A client asks for pain medication 1hr early75.A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns. The client asks the nurse to warm up seaweed soup that the client’spartner brought for her. Which of the following responses should the nurse make?a.“Does the doctor know you are eating that?”b.“Why are you eating seaweed soup?”c.“Of course I will heat that up for you”d.“The hospital good is more nutritious”76.A nurse is preparing an in-service for a group of nurses about malpractice issuesin nursing. Which of the following examples should the nurse include in the teaching?a.Leaving a nasogastric tube clamped after administering oral medicationb.Documenting communication with a provider in the progress notes of the client’s medical recordsc.Administering potassium via IV bolusd.Placing a yellow bracelet on a client who is at risk for falls
    77.A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching?a.Establish a toileting schedule for the clientb.Use clothing with buttons and sippersc.Discourage physical activity during the dayd.Engage the client in activities that increase sensory stimulation78.The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives?a.Hyperthyroidism.b.Thrombophlebitis.c.Diverticulosis.d.Hypocalcemia.79.A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, “It’s hard not to listen to the voices.” Which of the following questions should the nurse ask the client?a.“Do you understand that the voices are not real?”b.“Why do you think the voices are talking to you?”c.“Have you tried going to a private place when this occurs?”d.“What helps you ignore what you are hearing?”80.A charge nurse is teaching a group of newly licensed nurses about the correctuse of restraints. Which of the following should the nurse include in the teaching?a.Placing a belt restraint on a school-age child who has seizures.b.Securing wrist restraints to the bed rails for an adolescent.c.Applying elbow immobilizers of an infant receiving cleft lip injuryd.Keeping the side rails of a toddler’s crib elevated.81.A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following
    a.Inject air into the NPH insulin vial.b.(Unable to read)c.Withdraw the prescribed dose of regular insulind.Withdraw the prescribed dose of NPH insulin
    a. Teach the client to shift his weight every 15 min while sitting (cannot do this becausehe is paraplegic)82. A Nurse is working with a client who has an anxiety disorder and is in the orientation phaseof the therapeutic relationship. Which of the following statements should the nurse make duringthis phase?a. “Let’s talk about how you can change your response to stress.” B. “We should establish our roles in the initial session.”C. “Let me show you simple relaxation exercises to manage stress.”D. “We should discuss resources to implement in your daily life.”83. A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Whichof the following interventions should the nurse implement?a. Perform fundal massage ( massage if fundus is boggy)e. Insert an indwelling urinary catheter.f. Apply cold therapy to the client’s perineal area.( warm)84. A nurse is providing discharge teaching to a client who has cancer and a prescription for afentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching?e. Apply patch to your forearmf. Avoid high-fiber foods while taking this medicationg. Remove the patch for 8 hours every day to reduce the risk for tolerance.85. A nurse working on a surgical unit is developing a care plan for a client who has paraplegia.The client has an area of non-blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?b. Place the client upright on a donut-shaped cushionc. Assess pressure points every 24 hr.- must assessd. Turn and reposition the client every 3 hrs. while in bed. – must be q 2 hours in bed, 1hour in chair.86. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?d. We should discuss resources to implement in your daily lifee. Let me show you simple relaxation exercises to manage stress.f. Let’s talk about how you can change your response to stressb. Pour water from a squeeze bottle over the client’s perineal area.a. Avoid hot tub while wearing the patchd. We should establish our roles in the initial session.
35. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication?a. Avocadose. Pepperoni pizzaf. Smoked salmon 88. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?b. Rapid speech -severec. Feelings of dreadd. Purposeless activity89. A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.)b. Polydipsia = hyperglycemiac. Acetone Breath odor = DKA90. A nurse is caring for an infant who has coarctation of the aorta. Which of the followingshould the nurse identify as an expected finding?a. Upper extremity hypotensionb. Increased intracranial pressurec. Frequent nosebleeds91. A community health nurse is planning primary prevention activities to reduce the occurrenceof abuse. Which of the following strategies should the nurse include in the plan?a. Instruct healthcare professionals to identify abusive situations (screening=secondaryprevention)b. Locate financial support to open a shelter for abuse survivors (3rd)d. Connect abuse survivors with legal counsel (3rd)92. A nurse and an assistive personnel (AP) are caring for a group of clients. Which ofthe following tasks is appropriate for the nurse to delegate to the AP?a. Documenting the report of pain for a client who is postoperativeb. Administering oral fluids to a client who has dysphagia-b. Whole grain breada. Heightened perceptual fielda. Tremorsd.e.DiaphoresisInability to concentrated. Weak femoral pulsesc. Teach parenting skills to families at risk for abusec. Applying a condom catheter for a client who has a spinal cord injury
    d. Reviewing active range-of-motion exercise with a client who had a stroke93. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which ofthe following statements by the client indicates an understanding of the teaching?a. “I will take sucralfate with meals three times per day”c. “I will decrease my daily protein intake to 15 grams per day”d. “I will use ibuprofen as needed to control abdominal pain”94. A nurse is caring for a client who reports xerostomia following radiation therapy tothe mandible. Which of the following is an appropriate action by the nurse?a. Offer the client saltine crackers between mealsb. Suggest rinsing his mouth with an alcohol-based mouthwashc. Provide humidification of the room aird. Instruct the client on the use of esophageal speech95. A nurse is caring for four clients. Which of the following tasks can the nurse delegate toan assistive personnel?a. Assess effectiveness of antiemetic medication-b. Perform chest compressions during cardiac resuscitation-c. Perform a dressing change for a new amputee-d. Apply a transdermal nicotine patch-96. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender?a. The client takes vitamin C dailyb. The client has a history of alcohol use disorderd. The client takes furosemide twice daily97. A nurse is caring for a client who has major depressive disorder and a new prescription foramitriptyline. The nurse should monitor for which of the following adverse effects?a. Increased salivation- dry it will cause – anticholinergic effectsb. Weight lossd. Hypertension- orthostatic hypotension it will cause instead98. A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the b. “I will avoid food and beverages that contain caffeine”c. The client has a history of asthmaUrinary retention -c.
    following disorders is a contraindication for oral contraceptive use?a. Asthmac. Fibromyalgiad. Fibrocystic breast condition99. A nurse is providing teaching to a client who will undergo a magnetic resonanceimaging (MRI) scan. Which of the following statements is appropriate to include in the teaching?b. “You should not have this procedure if you have a tattoo.”c. “The nurse will ask you to wear protective eyewear during this procedure.”d. “The nurse will ask you to remove any transdermal patches prior to the procedure.”100. A nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit)–only tab shown is Tab 3:H&P: postmenopausal, hx DVT and iron deficiency anemia, works indoors, consumes 1-2alcoholic beverages per weeka. Vitamin Db. Vitamin Kc. Vitamin Ad. Vitamin B12101.A nurse is teaching who has chronic pain about avoiding constipation from opioid medications. Which of the following should the nurse include in the teaching?a.Drink 1.5L fluids each day.b.Take mineral oil at bedtime.c.Increase exercise activityd.Decrease insoluble fiber.102.A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching?a.“Drink 2 liters of warm water per day”.b.“Empty your bladder every 6 weeks.”.c.“Soak in a warm bath everyday”.d.“Take an oral estrogen tablet”. b. Hypertensiona. “You should not have this procedure if you are allergic to iodine.”
    103.A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?A. A client who has sinus arrhythmia and is receiving monitoring B. A client who has a hip fracture and a new onset of tachypneaC.A client who has epidural analgesia and weakness in the lower extremitiesD.A client who has diabetes and a hemoglobin A1C of 6.8%104.A nurse is providing dietary teaching to a client who has a new diagnosis ofirritable bowel syndrome. Which of the following recommendations should the nurseinclude?a.Consume food high in bran fiberb.Increase intake of milk productsc.Sweeten foods with fructose corn syrupd.Increase foods high in gluten105.A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?a.the infant 30 ml (1 oz) glucose water every 2 hr.b.Keep the infants head covered with a cap.c.Ensure that the newborn wears a diaper.d.Apply lotion to the newborn every 4 hr.106.A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?a.“(Unable to read) I feel to be in his best health care decision”b.“I will intervene if there is conflict between a client and his provider”c.“I should not advocate for a client unless he is able to ask me himself”d.“I will inform a client that his family should help make his health care decisions.”107.A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?a.Raise the side rails on both sides of the client’s bed during repositioning.b.Reposition the client without assistive devices.c.Discuss the client’s preferences for determining a reposition schedule.d.Evaluate the client’s ability to help with repositioning.108.A nurse is caring for an infant who has coaction of the aorta. Which of the
    following should the nurse identify as an expected finding?a.Weak femoral pulsesb.Frequent nosebleedsc.Upper extremity hypotensiond.Increased intracranial pressure109.A nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate?110.A nurse is assisting with the development of an informed document forparticipation in a research study. Which of the following information should thenurse include?A.A statement that participants can leave the study at will.B.An assignment of the participant to either the experimental or control group.C.A list of the clients participating in the study.D.A description of the framework the researchers will use to evaluate the data.111.A nurse is providing teaching to a client about the adverse effects ofsertraline. Which of the following adverse effects should the nurse include?
    a.Excessive sweatingb.Increased urinary frequencyc.Dry coughd.Metallic taste in mouth112.A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider?a.The client’s pulse oximetry level is 96%.b.(Unable to read)c.The client develops hiccups.d.The ECG shows pacing spikes after the QRS complex.113.A nurse is preparing discharge information for a client who has type 2 diabetesmellitus. Which of the following resources should the nurse provide to the client?a.Personal blogs about managing the adverse effects of diabetes medicationsb.Food label recommendations from the Institute of Medicinec.Diabetes medication information from the Physicians’ Desk Referenced. Food exchange lists for meal planning from the American DiabetesAssociation114.A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching?a.“The PCA will deliver a double dose of medication when you push the button twice.”b.“You can adjust the amount of pain medication you receive by pushing on the keypad.”c.“Continuous PCA infusion is designed to allow fluctuating plasma medication levels.”d.“You should push the button before physical activity to allow maximum pain control.”115.A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin?a.Glargine insulin.b.Regular insulin.c.NPH insulin.
    d.Insulin aspart.116.A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate?a.Looking at alphabet flashcards.b.Playing with a large plastic truck.c.Use scissors cut out paper shapes.d.Watching a cartoon in the dayroom.117.A nurse is caring for a client who is receiving intermittent feedings via a feedingvia a feeding pump and is experiencing dumping syndrome. Which of the following actions should the nurse take?a.Administer a refrigerated feeding.b.Increased the amount of water use to flush the tubing.c.(Unable to read) rate of the client’s feedings.d.Instruct the client to move onto their right side.118.A nurse in an emergency department is caring for a client who received a dose of penicillin and is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the following actions is the nurse’s priority?a.Monitor the client’s ECGb.Take the client’s vital signs.c.Administer oxygend.Insert an IV line.119.A nurse is caring for a client who has Raynaud’s disease. Which of the following actions should the nurse take?a.Provide information about stress management.b.Maintain a cool temperature in the client’s room.c.Administer epinephrine for acute episodes.d.Give glucocorticoid steroid twice per day.120.A nurse is reviewing the medical history of a client who has angina. Which of the following findings in the client’s medical history should identify as a risk factor for angina?a.Hyperlipidemia.
    b.COPD
    c.Seizure disorderd.Hyponatremia.121.A nurse is caring for a client who is 12 hr. postpartum and has a third- degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?a.Bisacodyl 10 mg rectal suppository.b.Magnesium hydroxide 30 ml PO.c.Famotidine 20 mg PO.d.Loperamide 4 mg PO.122.A nurse overhears two assistive personnel (AP) discussing care for a client while in the elevator. Which of the following actions should the nurse take?a.Contact the client’s family about the incident.b.Notify the client’s provider about the incident.c.File a complaint with the facility’s ethics committee.d.Report the incident to the AP’s charge nurse.123. A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which of the following instructions should the nurse take?a. . Administer the feeding over 30 min.b. Place the child in as supine position after the feeding.c. Charge the feeding bag and tubing every 3 days.d. Warm the formula in the microwave prior to administration.124. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider? A. Potassium level 4.2 mEq/L.B. Apical pulse 58/min.C. D igoxin level 1 ng/ml.D. Constipation for 2 days.125. A nurse is caring for a client who is comatose and has advance directives that indicate the clientdoes not want life-sustaining measures. The client’s family want the client to have life-sustainingmeasures. Which of the following action should the nurse take?A . Arrange for an ethics committee meeting to address the
    family’s concerns. B . Support the family’s decision and initiate life-sustaining measures.C. . Complete an incident report.D. . Encourage the family to contact an attorney.126. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? A. Store the glasses in a labeled case.B. Clean the glasses with hot water.C. Clean the glasses with a paper towel.D. Store the glasses on the bedside table.127. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching?A. Remove the protective gown after the client’s room.B. Place the client in a room with negative pressure.C. Wear gloves when providing care to the client.128.A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take?a.Insert an indwelling urinary catheter.b.Apply fetal heart rate monitor.c.Initiate fundal massage.d.Initiate an oxytocin IV infusion.129.A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. (Move the steps into the box on the right. Placing them in the order of performance)a.Identify family needs interventions using the nursing process.b.Record information about the home visit according to agency policy.c.Contact the family to determine availability and readiness to make an appointmentd.Discuss plans for future visits with the family.
    e.Clarify the reason for the referral with the provider’s office.130.A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make?a.“Your baby needs an IV because she is not producing any tears”b.“Your baby needs an IV because her fontanels are budging”c.“Your baby needs an IV because she is breathing slower than normal”d.“Your baby needs an IV because her heart rate is decreasing”131.A nurse is caring for a client who is receiving intermittent eternal tube feeding. Which of the following places the client at risk for aspiration?a.A residual of 65mL 1 hr postprandialb.A History of gastroesophageal reflux diseasec.Sitting in a high-Fowler’s position during the feedingd.Receiving a high osmolarity formula132.A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching?a.Take magnesium hydroxide for indigestionb.Drink at least 3L of fluid daily C. Eat 1g/kg of protein per dayD. Consume foods high in potassium133.A nurse on a telemetry unit is assessing a client who is receiving continuouscardiac monitoring. The client’s heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms?a.First degree AV blockb.Premature ventricular contraction.c.Sinus bradycardia.d.Atrial fibrillation.134.A nurse is supervising an assistive personnel (AP) who is feeding a client. Thenurse observes that the client coughs after each bite. After asking the AP to stop feeding the client, which of the following actions should the nurse take next?a.Provide the client with an instructional handout about swallowing exercises.b.Ask a speech therapist to evaluate the client’s ability to swallow.
    c.Discuss the manifestations of impaired swallowing with the AP.d.Listens to the client’s lung sounds.135. A nurse is developing a plan of care for a client who has schizophrenia and is experiencingauditory hallucinations. Which of the following actions should the nurse include in the plan?a. Ask the client directly what he is hearingb. Encourage the client to lie down in a quiet roomc. Avoid eye contact with the clientd. Refer to the hallucinations as if they are real136.The nurse is teaching a group of clients at a community health fair aboutgenetic disease. Which of the following statements by a client indicates an understanding of the teaching?a.“If there is a genetic risk for future pregnancies, we can get treatment now to prevent the disease”b.“There is no need to have genetic counseling if I know that I have a family history of mental illness.”c.“My family has genetic risk for breast cancer, so I am considering a total mastectomy”d.“Even if I have a genetic risk for a disease the chance I will get the disease is probably low due to current medical treatments.”137.A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching?a.“The cord stump will fall off in 5 days.”b.“Contact the provider if the cord stump turns black.”c.“Clean the base of the cord with hydrogen peroxide daily.”d. “Keep the cord stump dry until it falls off.”138.A nurse is providing teaching to a client who is on glucocorticoidtherapy. Which of the following statements by the client indicates anunderstanding of the teaching?a.“I have my eyes examines annually”b.“I take a calcium vitamin supplement daily”c.“I limit my intake of foods with potassium”d.“I constantly take my medication between 8 and 9 each evening”
    139.A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by a newly licensed nurse indicates an understanding of the teaching?a.Stands with feet together when lifting a client up in bed.b.Raises the client’s head of bed before pulling the cline up.c.Uses a mechanical lift to move client from bed to chair.d.Places a gait belt around the client’s upper chest before assisting a client to stand.140.A client is requesting information from a nurse about a nitrazine test. Which of the following statements should the nurse make?a.“Your bladder should be full prior to me performing this testb.“If this test is positive you will be required to have a non-stress test.c. “This test will determine if there is leaking amniotic fluid”d.“I will be taking a blood sample to test for changes in your hormones levels”
    141.A Nurse is assessing a client who has hyponatremia and is receiving IV fluid therapy. Which of the following findings indicate the client is developing a complication of therapy?a.Peripheral edemab.Increased thirst.c.Flattened neck veins.d.Hypotension142.A nurse is conducting a home visit for a family who has two young children. The nurse notes several welts across the backs of the legs of one of the children. Which of the following actions should the nurse take first?a.Document clinical findings.b.Contact child protective services.c.Refer the parents to a self-help group.d.Instruct the parents about methods of discipline.143.A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include?a.Encourage the client to floss daily.b.Remove fresh flowers from the client’s room.c.Provide the client what a stool softener.d.Avoid serving the client raw vegetable.144.A nurse is assessing a client who is 30 min postoperative following anarterial thrombectomy. Which of the following findings should the nurse to report?a.Chest painb.Muscle spasms.c.Cool, moist skin.d.Incisional pain.145.A nurse is caring for a client who has left-sided heart failure, and the provider is concerned that the client might develop (Unable to read) Which of the following actions should the nurse take?a.Maintain the client’s oxygen saturation level at 89%.b.Place the client’s lower extremities on two pillows.c.Recommended that the client follow a 3g sodium diet.d.Place the client in high fowler’s position.
36. A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which if the following findings should the nurse identify as a contraindication for heat therapy?A. PhlebitisB. Abdominal aortic aneurysmC. OsteoarthritisD. Peripheral neuropathy147. A nurse is providing teaching to a client who is to undergo a cardiac catheterization.Which of the following findings is expected during the procedure?A. Sensation of skin warmthB. HeadacheC. Increased salivationD. Numbness and tingling of the extremities148. A nurse is transcribing new medication prescriptions for a group of clients. For which ofthe following prescriptions should the nurse contact the provider for clarification?A. Lorazepam .5 mg PO one tablet dailyB. Hydrochlorothiazide 12.5 mg PO BIDC. Triamcinolone acetonide 100 mcg/inhalation two puffs TIDD. Zolpidem 10 mg PO one tablet at bedtime149. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?A. Swelling of the faceB. Urinary frequencyC. Faintness upon risingD. Bleeding gums150. A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following finding should the nurse identify as the priority?A. Excoriation of the skin on the neck and chestB. DysphagiaC. Client reports a pain level of 6 on scale from 0-10
    D. Xerostomia151. A nurse is assessing a client who is 2 hrs postpartum for uterine atony. Which of the following action should the nurse take?A. Monitor the client’s urinary outputB. Check the client VSC. Evaluate the client’s pain levelD. Palpate the client’s fundus152. A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?A. “This type of seizure can be mistaken for daydreaming”B. “The child usually has an aura prior to onset”C. This type of seizure last 30-60 sec”D. “This type of seizure has a gradual onset”153. A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following is appropriate for this client?A. Disinfect and powder any latex products before useB. Tape stockinet over monitoring device and cordsC. Schedule the client as the last surgery of the dayD. Remove poop-socks from the IV154.A nurses is assessing a preschooler who has recently experienced an unexpected death in the family. Which of the following should the nurse recognize as an expected finding?a.The child expresses curiosity about the death process.b.The child refuses to talk about death.c.The child believes the person will return.d.The child focuses on his own mortality.155.A nurse is assessing a client in the emergency department. Which of the following actions should the nurse take first?Exhibit 1Laboratory Results Cerebrospinal fluid WBC 2,000/mm3 Neutrophils 88% Protein 320 mg/dl Glucose 35 mg/dl Cloudy in appearance
    Exhibit 2History and PhysicalReports severe headache and photophobia. Disoriented to person, place, and time. Lethargic.Exhibit 3 Vital SignsBP 166/96 mm Hg Respiratory rate 24/min Pulse rate 112/minTemperature 39.3C (102.8F) Pain of 6 on a scale from 0 to 10 Glasgow score 9a.Place the client on a cooling blanket.b.Administer an analgesic.c.Obtain arterial blood gas levels.d.Elevate the head of the client’s bed 30 degrees.156.A client is caring for a client following a paracentesis. Which of the following findings should the nurse identify as an indication of a complication?a.Decreased hematocrit.b.Increased blood pressure.c.Tachycardia.d.Hypothermia.157. A certified IV nurse is providing education about peripherally inserted catheters (PICC) to anewly licensed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of the teaching?a. “Use a vein in the middle of the lower arm to insert a PICC.”b. “Flush a PICC using a 3-milliliter syringe.”c. “Informed consent is required prior to PICC placement.”d. “Position the client’s arm in adduction for PICC placement.”158.A nurse is reviewing admission prescriptions for a group of clients. Which of the following prescriptions should the nurse identify as complete?a.Furosemide 20 mg BIDb.Nitroglycerin transdermal patch.c.Aspirin 1 tablet daily.d.Metoprolol 5mg IV now.159.A nurse is caring a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?a.Hold hand flat to perform percussion on the child
    b.Perform the procedure twice a dayc.Administer a bronchodilator after the procedured. D. Perform the procedure prior to meals160.A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow up care?a.A client who received a Mantoux test 48hr ago and has an indurationb.A client who is schedule for a colonoscopy and is taking sodium phosphatec.A client who is taking warfarin and has an INR of 1.8d.A client who is takin bumetanide and has a potassium level of 3.6 mEq/ L161.A nurse is caring for a client who is postpartum and request information aboutcontraception. Which of the following instructions should the nurse include?a.“The lactation amenorrhea method is effective for your first year postpartum”b.“You can continue to use the diaphragm used before your pregnancy”c.“Place transdermal birth control patch on your upper arm”d.“I should avoid vaginal spermicides while breast feeding.”162.A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching?a.“Staff will apply identification band after first bath”b.“I will not publish public announcement about my baby’s birth”c.“I can remove my baby’s identification band as long as she is in my room”d.“I can leave my baby in my room while I walk in the hallway”163.A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan?a.Restrict the client’s total fluid intake to 250 mL/hrb.Give the protamine if signs of magnesium sulfate toxicity occurc.Monitor the FHR via Doppler every 30mind. Measure the client’s urine output every hour164.A nurse is receiving a telephone prescription from a provider for a client who
    requires additional medication for pain control. Which of the following entries should the nurse make in the medical record?a.“Morphine 3 mg SQ every 4 hr. PRN for pain.”b.“Morphine 3 mg Subcutaneous (Unable to read)c.“Morphine 3.0 mg sub q every 4 hr. PRN for pain.”d.“Morphine 3 mg SC q 4 hr. PRN for pain.”165.A nurse is assessing a client who has acute kidney injury and a respiratory rate of 34/min. The client’s ABG results are ph. 7.28 HCO3 18 mEq/L. (Unable to read) PaO2 90 mm Hg. Which of the following conditions should the nurse expect?a.Metabolic acidosis.b.Metabolic alkalosis.c.Respiratory acidosis.d.Respiratory alkalosis.166.A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?a.Notify the provider.b.Report the incident to the nurse manager.c.Monitor vital signs.d.Fill out an incident report.167.A nurse receives a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of thefollowing instructions should the nurse provide to the provider?a.“Have your child lie down and turn their head to their side for 10 minutes”b.“Use your thumb and forefinger to apply pressure to the (Unable to read) of your child’s nose”c.“Place a warm wet washcloth over your child’s forehead and the bridge of their nose”d.“Tell your child to blow their nose gently and then sit down and tilt your head back”168.A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client?a.Match the client’s blood type with the type and cross match specimens.b.Confirm the provider’s prescription matches the number on the blood
    component.c.Ask the client to state the blood type and the date of their last blood donation.d.Ensure that the client’s identification band matches the number on the blood unit.169.A nurse is transcribing new medication prescriptions for a group of client. For which of the following prescriptions should the nurse contact the provider for clarifications?a.Zolpidem 10mg PO one tablet at bedtimeb.Hydrochlorothiazide 12.5 mg PO BIDc.Triamcinolone acetonide 100 mcg/inhalation two puffs TIDd.Lorazepam .5mg PO one tablet daily170. A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate?a. Administer enalapril 2.5 mg PO twice dailyb. Ambulate the client every 4 hr while awake(bedrest)c. Provide the client with 4 g sodium diet(d. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr171. A nurse is collecting a specimen for urinalysis and culture from a client who has anindwelling urinary catheter. Which of the following actions should the nurse take duringcollection?a. Drain the specimen from the drainage bag(not sterile use the port for culture and UA)b. Clamp the catheter distal to the injection portc. Collect 2 mL of urine for each specimend. Obtain the urinalysis specimen before the culture specimen172. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitorthe client for which of the following manifestations?A. Orthostatic HypertensionB. Dependent EdemaC. Decreased HematocritD. Neck Vein Distension173. A nurse is devdeloping an in-service about personality disorders. Which of the followinginformation should the nurse include when discussing borderline personality disorder?A. The client is overly concerned about minor details.B. The client exhibits impulsive behavior.
    C. The client is exceptionally clingy to others.D. The client may act seductively.- histrionic174. A nurse is assessing a client who is 36 weeks of gestation. Which of the following findingsshould the nurse report to the provider?A. 3+ deep tendon reflexes (common finding in women with preeclampsia and does not requireaction unless there are symptoms of magnesium toxicity.)B. Protruding HemorrhoidsC. Urinary Frequency (expected)D. Supine Hypotension
37. A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to takefirst?A. Inform the provider of the time of the last dose of pain medication.B. Document the sequence of events as they occur.C. Provide non-pharmacological pain management interventions.D. Instruct the client about the steps of the procedure.176. A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?A. The client was intubated without complications.B. The estimated blood loss was 250 milliliters.C. There was a total of 10 sponges used during the procedures.D. The client is a member of the board of directors.177. A nurse is providing teaching about digoxin administration to the parents ofa toddler who has heart failure. Which of the following statements should the nurse include in the teaching?A. “You can add the medication to a half-cup of your child’s favorite juice.”B. “Repeat the dose if your child vomits within 1 hour after taking the medication.”C. “Limit your child’s potassium intake while she is taking this medication.”D. “Have your child drink a small glass of water after swallowing the medication.”178. A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?A. Left ventricular failureB. Cardiogenic shockC. HypovolemiaD. Hypotension
38. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?A. A client who has COPD and a respiratory rate of 44/minB. A client who has cancer with a sealed implant for radiation treatment.C. A client who is 1 day postoperative following a vertebroplastyD. A client who is receiving heparin for deep vein thrombosis.180. A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery?A. Fasting blood glucose 108 mg/dl (WNL)B. WBC 9,800/mm (WNL)C. Creatinine 0.9 mg/dl (WNL)D. Potassium 5.2 mEq/L