PN HESI Exit V3
1) The LPN/LVN receives the client’s next scheduled bag of TPN labeled with the
additive NPH insulin. Which action should the nurse implement?
A.Hang the solution at the current rate.
B.Refrigerate the solution until needed.
C.Prepare the solution with new tubing.
D.Return the solution tothe pharmacy.
Correct Answer: D Return the solution to the pharmacy.
2) A male client has just undergone a laryngectomy and has a cuffed tracheostomy
tube inplace. When initiating bolus tube feedings postoperatively, when should the
nurse inflate the cuff?
A.Immediately after feeding
B.Just prior totube feeding
C.Continuous inflation isrequired
D.Inflation is not required
Correct Answer: B Just prior to tube feeding
3) A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid
ventricular response. Based onthis finding, the nurse anticipates assisting the
physician with which treatment?
A.Administer lidocaine,75 mgintravenous push.
B.Perform synchronized cardioversion.
C.Defibrillate the client assoon aspossible.
D.Administer atropine, 0.4 mgintravenous push.
Correct Answer: B Perform synchronized cardioversion.
4) A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an
ulcer onthe heel ofthe left foot that has not healed with wound care. The nurse
observes that the entire left foot is darker incolor than the right foot. Which
additional symptom should the nurse expect tofind?
A. Pedal pulses will be weak or absent in the left foot.
B. The client will state that the left foot is usually warm.
C. Flexion and extension of the left foot will be limited.
D.Capillary refill ofthe client’s left toes will bebrisk.
Correct Answer: APedal pulses will be weak or absent in the left foot.
5) A client with cirrhosis develops increasing pedal edema and ascites. Which
dietary modification ismost important for the nurse to teach this client?
A.Avoid high-carbohydrate foods.
B.Decrease intake offat-soluble vitamins.
C.Decrease caloric intake.
D.Restrict salt and fluid intake.
Correct Answer: D Restrict salt and fluid intake.
6) During report, the nurse learns that a client with tumor lysis syndrome is
receiving an IVinfusion containing insulin. Which assessment should the nurse
complete first?
A. Review the client’s history for diabetes mellitus.
B. Observe the extremity distal to the IV site.
C. Monitor the client’s serum potassium and blood glucose levels.
D.Evaluate the client’soxygen saturation and breath sounds.
Correct Answer: C Monitor the client’s serum potassium and blood glucose levels.
7) A resident in a long-term care facility is diagnosed with hepatitis B. Which
intervention should the nurse implement with the staff caring for this client?
A.Determine ifall employees have had the hepatitis B vaccine series.
B.Explain that this type ofhepatitis can be transmitted when feeding the client.
C.Assure the employees that they cannot contract hepatitis B when providing
direct care.
D.Tell the employees that wearing gloves and a gown are required when providing
care.
Correct Answer: A Determine if all employees have had the hepatitis B vaccine
series.
8) The LPN/LVN notes that the client’s drainage has decreased from 50 to 5 mL/hr
12 hours after chest tube insertion for hemothorax. What is the best initial action
for the nurse to take?
A. Document this expected decrease in drainage.
B. Clamp the chest tube while assessing for air leaks.
C.Milk the tube toremove any excessive blood clot buildup.
D.Assess for kinks or dependent loops in the tubing.
Correct Answer: D Assess for kinks or dependent loops in the tubing.
9) The nurse notes that a client who is scheduled for surgery the next morning has
an elevated blood urea nitrogen (BUN) level. Which condition is most likely to
have contributed to this finding?
A.Myocardial infarction 2 months ago
B.Anorexia and vomiting for the past 2 days
C.Recently diagnosed type2 diabetes mellitus
D.Skeletal traction for a right hip fracture
Correct Answer: B Anorexia and vomiting for the past 2 days
10) The nurse is reviewing routine medications taken by a client with chronic angle
closure glaucoma. Which medication prescription should the nurse question?
A.Antianginal with a therapeutic effect ofvasodilation
B.Anticholinergic with a side effect ofpupillary dilation
C.Antihistamine with a side effect ofsedation
D.Corticosteroid with a side effect ofhyperglycemia
Correct Answer:B Anticholinergic with a side effect of pupillary dilation
11) A 58-year-old client who has no health problems asks the nurse about
receiving the pneumococcal vaccine (Pneumovax). Which statement given bythe
nurse would offer the client accurate information about this vaccine?
A. The vaccine is given annually before the flu season to those older than 50 years.
B. The immunization is administered once to older adults or those at risk for illness.
C. The vaccine is for all ages and is given primarily to those persons traveling
overseas to areas of infection.
D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5
years.
Correct Answer: B The immunization is administered once to older adults or those
at risk for illness.
12) The nurse is assessing a male client with acute pancreatitis. Which finding
requires the MOST immediate intervention by the nurse?
A. The client’s amylase level is three times higher than the normal level.
B. While the nurse is taking the client’s blood pressure, he has a carpal spasm.
C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7.
D. The client states that he will continue to drink alcohol after going home.
Correct Answer: B While the nurse is taking the client’s blood pressure, he has a
carpal spasm.
13) During assessment of a client in the intensive care unit, the nurse notes
that the client’s ARE CLEAR UPON AUSCULTATION, but jugular vein
distention and muffled heart sounds are present. Which intervention should the
nurse implement?
A.Prepare the client for a pericardial tap.
B.Administer intravenous furosemide (Lasix).
C.Assist the client tocough and breathe deeply.
D.Instruct the client torestrict the oral fluid intake.
Correct Answer: A. Prepare the client for a pericardial tap.
14) After attending a class on reducing cancer risk factors, a client selects bran
flakes with 2%milk and orange slices from a breakfast menu. Inevaluating
the client’s learning, the nurse affirms that the client has made good choices
and makes what additional recommendation?
A. Switch to skim milk.
B. Switch to orange juice.
C. Add a source of protein.
D. Add herbal tea.
Correct Answer: A Switch to skim milk.
15) A client diagnosed with angina pectoris complains of chest pain while
ambulating inthe hallway. Which action should the nurse implement first?
A. Support the client to a sitting position.
B. Ask the client to walk slowly back to the room.
C.Administer a sublingual nitroglycerin tablet.
D.Provide oxygen via nasal cannula.
Correct Answer: A. Support the client to a sitting position.
16) A client is diagnosed with an acute small bowel obstruction. Which
assessment finding requires the most immediate intervention bythe nurse?
A. Fever of 102° F
B. Blood pressure of 150/90 mm Hg
C.Abdominal cramping
D.Dry mucous membranes
Correct Answer: AFever of 102° F
17) A tornado warning alarm has been activated at the local hospital. Which
action should the charge nurse working ona surgical unit implement first?
A. Instruct the nursing staff to close all window blinds and curtains in clients’
rooms.
B. Move clients and visitors into the hallways and close all doors to clients’
rooms.
C. Visually confirm the location of the tornado by checking the windows on
the unit.
D. Assist all visitors with evacuation down the stairs in a calm and orderly
manner.
Correct Answer: B. Move clients and visitors into the hallways and close all doors
to clients’ rooms.
18) A client with alcohol-related liver disease is admitted to the unit. Which
prescription should the nurse call the health care provider about for
reverification for this client?
A.Vitamin K1(AquaMEPHYTON), 5 mg IMdaily
B.High-calorie, low-sodium diet
C.Fluid restriction to1500 mL/day
D.Pentobarbital (Nembutal sodium) atbedtime for rest
Correct Answer: D. Pentobarbital (Nembutal sodium) at bedtime for rest
19) A female client who received a nephrotoxic drug is admitted with acute
renal failure and asks the nurse ifshe will need dialysis for the rest of her life.
Which pathophysiologic consequence should the nurse explain that supports
the need for temporary dialysis until acute tubular necrosis subsides?
A.Azotemia
B.Oliguria
C.Hyperkalemia
D.Nephron obstruction
Correct Answer: D Nephron obstruction
20) Which instruction should the nurse teach a female client about the
prevention oftoxic shock syndrome?
A. “Get immunization against human papillomavirus (HPV).”
B. “Change your tampon frequently.”
C. “Empty your bladder after intercourse.”
D. “Obtain a yearly flu vaccination.”
Correct Answer: B. “Change your tampon frequently.”
21) A postoperative client receives a Schedule II opioid analgesic for pain.
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nurse?
A.Hypoactive bowel sounds with abdominal distention
B.Client reports continued pain of8 ona 10-point scale
C.Respiratory rate of 12breaths/min, with O2saturation of85%
D.Client reports nausea after receiving the medication
Correct Answer: C Respiratory rate of 12 breaths/min, with O2 saturation of 85%
22) A client is being discharged following radioactive seed implantation for
prostate cancer. What isthe most important information that the nurse should
provide to this client’s family?
A.Follow exposure precautions.
B.Encourage regular meals.
C.Collectall urine.
D.Avoid touching the client.
Correct Answer: A.Follow exposure precautions.
23) An emaciated homeless client presents to the emergency department
complaining ofa productive cough, with blood-tinged sputum and night
sweats. Which action ismost important for the emergency department triage
nurse to implement for this client?
A. Initiate airborne infection precautions.
B. Place a surgical mask on the client.
C. Don an isolation gown and latex gloves.
D. Start protective (reverse) isolation precautions.
Correct Answer: A.Initiate airborne infection precautions.
24) Which abnormal laboratory finding indicates that a client with diabetes
needs further evaluation for diabetic nephropathy?
A.Hypokalemia
B.Microalbuminuria
C.Elevated serum lipid levels
D.Ketonuria
Correct Answer: B.Microalbuminuria
25) An older client is admitted with a diagnosis of bacterial pneumonia.
Which symptom should the nurse report to the health care provider after
assessing the client?
A.Leukocytosis and febrile
B.Polycythemia and crackles
C.Pharyngitis and sputum production
D.Confusion and tachycardia
Correct Answer: D Confusion and tachycardia
26) Which nursing action is necessary for the client with a flail chest?
A.Withhold prescribed analgesic medications.
B.Percuss the fractured rib area with light taps.
C.Avoid implementing pulmonary suctioning.
D.Encourage coughing and deep breathing.
Correct Answer: D Encourage coughing and deep breathing.
27) When assigning clients on a medical-surgical floor to an RN and a PN, it
is best for the charge nurse to assign which client to the PN?
A.A young adult with bacterial meningitis with recent seizures
B.An older adultclient with pneumonia and viral meningitis
C.A female client inisolation with meningococcalmeningitis
D.A male client 1 day postoperative after drainage ofa brain abscess
Correct Answer: B An older adult client with pneumonia and viral meningitis
28) When educating a client after a total laryngectomy, which instruction
would be most important for the nurse toinclude inthe discharge teaching?
A.Recommend that the client carry suction equipment atall times.
B.Instruct the client tohave writing materials with him atall times.
C.Tell the client tocarry a medical alert card that explains his condition.
D.Caution the client not totravel outside the United States alone.
Correct Answer: C. Tell the client to carry a medical alert card that explains his
condition.
29) A central venous catheter has been inserted via a jugular vein, and a
radiograph has confirmed placement ofthe catheter. A prescription has been
received for a medication STAT, but IV fluids have not yet been started.
Which action should the nurse take prior toadministering the prescribed
medication?
A. Assess for signs of jugular venous distention.
B. Obtain the needed intravenous solution.
C. Flush the line with heparinized solution.
D. Flush the line with normal saline.
Correct Answer: D.Flush the line with normal saline.
30) In caring for a client with acute diverticulitis, which assessment data
warrants immediate nursing intervention?
A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C. The client is refusing to eat any of the meal and is complaining of nausea.
D. The client has not had a bowel movement in 2 days and has a soft abdomen.
Correct Answer: A.The client has a rigid hard abdomen and elevated WBC.
31) The nurse is giving preoperative instructions to a 14-year-old client
scheduled for surgery tocorrect a spinal curvature. Which statement bythe
client best demonstrates that learning has taken place?
A. “I will read all the teaching booklets you gave me before surgery.”
B. “I have had surgery before, so I know what to expect afterward.”
C. “All the things people have told me will help me take care of my back.”
D. “Let me show you the method of turning I will use after surgery.”
Correct Answer: D.”Let me show you the method of turning I will use after
surgery.”
32) The nurse on a medical surgical unit is receiving a client from the
postanesthesia care unit (PACU) with a Penrose drain. Before choosing a
room for this client, which information ismost important for the nurse to
obtain?
A. If suctioning will be needed for drainage of the wound
B. If the family would prefer a private or semiprivate room
C. If the client also has a Hemovac in place
D. If the client’s wound is infected
Correct Answer: D If the client’s wound is infected
33) The nurse is completing an admission interview for a client with
Parkinson’s disease. Which question will provide additional information about
manifestations that the client is likely toexperience?
A. “Have you ever experienced any paralysis of your arms or legs?”
B. “Do you have frequent blackout spells?”
C. “Have you ever been frozen in one spot, unable to move?”
D. “Do you have headaches, especially ones with throbbing pain?”
Correct Answer: C. “Have you ever been frozen in one spot, unable to move?”
34) A hospitalized client is receiving nasogastric tube feedings via a small-
bore tube and a continuous pump infusion. Hebegins tocough and produces a
moderate amount ofwhite sputum. Which action should the nurse take
FIRST?
A.Auscultate the client’s breath sounds.
B.Turn off the continuous feeding pump.
C.Check placement ofthe nasogastric tube.
D.Measure the amountofresidual feeding.
Correct Answer: B.Turn off the continuous feeding pump.
35) The nurse is caring for a critically ill client with cirrhosis of the liver who
has a nasogastric tube draining bright red blood. The nurse notes that the
client’s serum hemoglobin and hematocrit levels are decreased. Which
additional change inlaboratory data should the nurse expect?
A.Increased serum albumin level
B.Decreased serum creatinine
C.Decreased serum ammonia level
D.Increased liver function test results
Correct Answer: C.Decreased serum ammonia level
36) During the shift report, the charge nurse informs a nurse that she has been
assigned toanother unit for the day. The nurse begins tosigh deeply and
tosses about her belongings asshe prepares toleave, making itknown that she
is very unhappy about being floated to the other unit. What is the best
immediate action for the charge nurse to take?
A. Continue with the shift report and talk to the nurse about the incident at a
later time.
B. Ask the nurse to call the house supervisor to see if she must be reassigned.
C. Stop the shift report and remind the nurse that all staff are floated equally.
D. Inform the nurse that her behavior is disruptive to the rest of the staff.
Correct Answer: A.Continue with the shift report and talk to the nurse about the
incident at a later time.
37) The LPN/LVN is administering a nystatin suspension (Mycostatin) for
stomatitis. Which instruction will the nurse provide tothe client when
administering this medication?
A. “Hold the medication in your mouth for a few minutes before swallowing
it.”
B. “Do not drink or eat milk products for 1 hour prior to taking this
medication.”
C. “Dilute the medication with juice to reduce the unpleasant taste and odor.”
D. “Take the medication before meals to promote increased absorption.”
Correct Answer: “Hold the medication in your mouth for a few minutes before
swallowing it.”
38) Which condition should the nurse anticipate as a potential problem in a
female client with a neurogenic bladder?
A.Stress incontinence
B.Infection
C.Painless gross hematuria
D.Peritonitis
Correct Answer: B.Infection
39) A client is ready for discharge following the creation of an ileostomy.
Which instruction should the nurse include in discharge teaching?
A. Replace the stoma appliance every day.
B. Use warm tap water to irrigate the ileostomy.
C. Change the bag when the seal is broken.
D. Measure and record the ileostomy output.
Correct Answer: C.Change the bag when the seal is broken.
40) In assessing a client with an arteriovenous (AV) shunt who is scheduled
for dialysis today, the nurse notes the ABSENCE ofa thrill or bruit atthe
shunt site. What action should the nurse take?
A.Advise the client that the shunt isintact and ready for dialysis asscheduled.
B.Encourage the client tokeep the shunt site elevated above the level ofthe
heart.
C.Notify the health care provider ofthe findings immediately.
D.Flush the site atleast once with a heparinized saline solution.
Correct Answer: C.Notify the health care provider of the findings immediately.
41) The nurse is preparing a 45-year-old client for discharge from a cancer
center following ileostomy surgery for colon cancer. Which discharge goal
should the nurse include in this client’s discharge plan?
A.Reduce the daily intake ofanimal fat to10% ofthe diet within 6weeks.
B.Exhibit regular, soft-formed stool within 1 month.
C.Demonstratethe irrigation procedure correctly within 1 week.
D.Attend anostomy support group within 2 weeks.
Correct Answer: D.Attend an ostomy support group within 2 weeks.
42) A client with hypertension has been receiving ramipril (Altace), 5 mg PO,
daily for 2 weeks and isscheduled to receive a dose at 0900. At 0830, the
client’s blood pressure is120/70 mmHg. Which action should the nurse take?
A.Administerthe prescribed dose atthe scheduled time.
B.Hold the dose and contact the health care provider.
C.Hold the dose and recheck the blood pressure in 1 hour.
D.Check the health care provider’s prescription toclarify dose.
Correct Answer: A.Administer the prescribed dose at the scheduled time.
43) A client with type 2 diabetes takes metformin (Glucophage) daily. The
client isscheduled for major surgery requiring general anesthesia the next day.
The nurse anticipates which approach tomanage the client’s diabetes best
while the client is NPO during the perioperative period?
A.NPO except for metformin and regular snacks
B.NPO except for oral antidiabetic agent
C.Novolin N insulin subcutaneously twice daily
D.Regular insulin subcutaneously per sliding scale
Correct Answer: D.Regular insulin subcutaneously per sliding scale
44) The nurse is assessing a 75-year-old client for symptoms of
hyperglycemia. Which symptom ofhyperglycemia is anOLDER adult most
likely to exhibit?
A.Polyuria
B.Polydipsia
C.Weight loss
D.Infection
Correct Answer: D.Infection
45) The nurse teaches a client with type 2 diabetes nutritional strategies to
decrease obesity. Which food item(s) chosen bythe client INDICATES
UNDERSTANDING ofthe teaching? (Select all that apply.)
A. White bread
B.Salmon
C.Broccoli
D.Whole milk
E.Banana
Correct Answer: B, C,E
B. Salmon
C.Broccoli
E.Banana
46) A practical nurse (PN) tells the charge nurse in a long-term facility that
she does not want to beassigned toone particular resident. She reports that the
male client keeps insisting that she ishis daughter and begs her to stay inhis
room. What is the best managerial decision?
A. Notify the family that the resident will have to be discharged if his behavior
does not improve.
B. Notify administration of the PN’s insubordination and need for counseling
about her statements.
C. Ask the PN what she has done to encourage the resident to believe that she
is his daughter.
D. Reassign the PN until the resident can be assessed more completely for
reality orientation.
Correct Answer: D Reassign the PN until the resident can be assessed more
completely for reality orientation.
47) The nurse is preparing a teaching plan for a group of healthy adults.
Which individual ismost likely tomaintain optimum health?
A.A teacher whose blood glucose levels average 126mg/dL daily with oral
anti diabetic drugs
B.An accountant whose blood pressure averages 140/96 mm Hgand who says
he does not have time to exercise
C.A stock broker whose total serum cholesterol level dropped to290 mg/dL
with diet modifications
D.A recovering IVheroin user who contracted hepatitis more than 10years
ago
Correct Answer: A.A teacher whose blood glucose levels average 126 mg/dL daily
with oral anti diabetic drugs
48) What is the most important nursing priority for a client who has been
admitted for a possible kidney stone?
A.Reducing dairy products inthe diet
B.Straining all urine
C.Measuring intake and output
D.Increasing fluid intake
Correct Answer: B.Straining all urine
49) A client is admitted to the hospital with a diagnosis of severe acute
diverticulitis. Which nursing intervention has the highest priority?
A. Place the client on NPO status.
B. Assess the client’s temperature.
C. Obtain a stool specimen.
D.Administer IV fluids.
Correct Answer: A.Place the client on NPO status.
50) The nurse includes frequent oral care in the plan of care for a client
scheduled for an esophagogastrostomy for esophageal cancer. This
intervention isincluded inthe client’s plan ofcare toaddress which nursing
diagnosis?
A.Fluid volume deficit
B.Self-care deficit
C.Risk for infection
D.Impaired nutrition
Correct Answer: C.Risk for infection
51) A family member was taught to suction a client’s tracheostomy prior to the
client’s discharge from the hospital. Which observation bythe nurse indicates
that the family member iscapable ofcorrectly performing the suctioning
technique?
A. Turns on the continuous wall suction to −190 mm Hg
B. Inserts the catheter until resistance or coughing occurs
C.Withdraws the catheter while maintaining suctioning
D.Reclears the tracheostomy after suctioning the mouth
Correct Answer: B.Inserts the catheter until resistance or coughing occurs
52) A client diagnosed with chronic kidney disease (CKD) 2 years ago is
regularly treated ata community hemodialysis facility. Before his scheduled
dialysis treatment, which electrolyte imbalance should the nurse anticipate?
A.Hypophosphatemia
B.Hypocalcemia
C.Hyponatremia
D.Hypokalemia
Correct Answer: B Hypocalcemia
53) As an adolescent is receiving care, he’s inadvertently injured with a warm
compress. The nurse completes anincident report based onthe knowledge that
identification of which ofthe following is a goal ofthe report?
1. To reprimand the involved staff members for their actions
2. To identify the learning needs of staff to prevent incident recurrences
3. To reprimand the nurse-manager responsible for the unit
4. To hold people accountable for their actions
Correct Answer: 2
54) As a client progresses through pregnancy, she develops constipation. What
is the primary cause of this problem during pregnancy?
1. Decreased appetite
2. Inadequate fluid intake
3. Prolonged gastric emptying
4. Reduced intestinal motility
Correct Answer: 4 Reduced intestinal motility
55) An adolescent with type 1 diabetes mellitus is experiencing a growth
spurt. Which treatment approach would bemost effective for this client?
1. Administering insulin once per day
2. Administering multiple doses of insulin
3. Limiting dietary fat intake
4. Substituting an oral anti diabetic agent for insulin
Correct Answer: 2. Administering multiple doses of insulin
56) A client is admitted to the health care facility with bowel obstruction
secondary tocolon cancer. The nurse obtains a health history, measures vital
signs, and auscultates for bowel sounds. Which step ofthe nursing process is
the nurse performing?
1. Planning
2. Data collection
3. Evaluation
4. Implementation
Correct Answer: 2. Data collection
57) The physician prescribes meperidine (Demerol), 1.1 mg/kg I.M., for a 16-
month-old child who has just had abdominal surgery. When administering this
drug, the nurse should use a needle of which size?
1. 18G
2. 20G
3. 23G
4. 27G
Correct Answer: 3 23G
58) Which finding in a neonate suggests hypothermia?
1. Bradycardia
2. Hyperglycemia
3. Metabolic alkalosis
4. Shivering
Correct Answer: 1 Bradycardia
59) Initial client assessment information includes blood pressure 160/110 mm
Hg, pulse 88beats/minute, respiratory rate 22breaths/minute, and reflexes
+3/+4 with 2 beat clonus. Urine specimen reveals +3protein, negative sugar
and ketones. Based onthese findings, the nurse would expect the client to
have which complaints?
1. Headache, blurred vision, and facial and extremity swelling
2. Abdominal pain, urinary frequency, and pedal edema
3. Diaphoresis, nystagmus, and dizziness
4. Lethargy, chest pain, and shortness of breath
Correct Answer: 1. Headache, blurred vision, and facial and extremity swelling
60) The nurse is performing a baseline assessment of a client’s skin integrity.
Which of the following is a key assessment parameter?
1. Family history of pressure ulcers
2. Presence of existing pressure ulcers
3. Potential areas of pressure ulcer development
4. Overall risk of developing pressure ulcers
Correct Answer: 4. Overall risk of developing pressure ulcers
61) The nurse is preparing to boost a client up in bed. She instructs the client
to use the overbed trapeze. Which risk factor for pressure ulcer development is
the nurse reducing by instructing the client to move in this manner?
1. Friction
2. Impaired circulation
3. Localized pressure
4. Shearing forces
Correct Answer: 4. Shearing forces
62) A geriatric client with Alzheimer’s disease has been living with his grown
child’s family for the last 6 months. He wanders atnight and needs help with
activities ofdaily living. Which statement byhis child suggests that the family
is successfully adjusting to this living arrangement?
1. “It’s difficult dealing with Dad. It’s a thankless job.”
2. “We had no idea this would be so difficult. It’s our cross to bear.”
3. “Dad really seems to be making progress. We’re hoping he’ll be able to
move back into his house soon.”
4. “Dad has presented many challenges. We have alarms on all the outside
doors now. Respite care gives usa break.”
Correct Answer: 4 “Dad has presented many challenges. We have alarms on all
the outside doors now. Respite care gives us a break.”
63) The nurse is assessing an elderly client. When performing the assessment,
the nurse should consider that one normal age-related change is:
1. cloudy vision.
2. incontinence.
3. diminished reflexes.
4. tremors.
Correct Answer: 3 diminished reflexes.
64) An agitated, confused client arrives in the emergency department. The
client’s history includes type 1diabetes, hypertension, andangina pectoris.
Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat
blood glucose sample measures 42mg/dl, and the client istreated foranacute
hypoglycemic reaction. After recovery, the nurse teaches the client totreat
hypoglycemiaby ingesting:
1. 2 to 5 g of a simple carbohydrate.
2. 10 to 15 g of a simple carbohydrate.
3. 18 to 20 g of a simple carbohydrate.
4. 25 to 30 g of a simple carbohydrate.
Correct Answer: 210 to 15 g of a simple carbohydrate.
65) A 43-year-old man was transferring a load of firewood from his front
driveway to his backyard woodpile at 10 a.m. when heexperienced a
heaviness in his chest and dyspnea. He stopped working and rested, and the
pain subsided. Atnoon, the pain returned. At1:30 p.m., his wife took him to
the emergency department. Around 2 p.m., the emergency department
physician diagnoses ananterior myocardial infarction (MI). The nurse should
anticipate which immediate order by the physician?
1. Lidocaine administration
2. Cardiac stress test
3. Serial liver enzyme testing
4. Tissue plasminogen activator (tPA)
Correct Answer: 4. Tissue plasminogen activator (tPA)
66) A nurse’s neighbor complains of severe right flank pain. She explains that
it began during the night, but she was able to take acetaminophen (Tylenol)
and return tobed. When she awoke, the pain increased inintensity. How
should the nurse intervene?
1. Explain that she can’t give medical advice.
2. Inform the neighbor that she might require surgery.
3. Advise the neighbor to seek medical attention.
4. Tell the neighbor that she’ll be fine because she was able to get through the
night.
Correct Answer: 3. Advise the neighbor to seek medical attention.
67) A client has a history of chronic undifferentiated schizophrenia. Because
she has a history ofnoncompliance with antipsychotic therapy, she’ll receive
fluphenazine decanoate (Prolixin Decanoate) injections every 4 weeks. Before
discharge, what should the nurse include inher teaching plan?
1. Asking the physician for droperidol (Inapsine) to control any
extrapyramidal symptoms that occur
2. Sitting up for a few minutes before standing to minimize orthostatic
hypotension
3. Notifying the physician if her thoughts don’t normalize within 1 week
4. Expecting symptoms of tardive dyskinesia to occur and to be transient
Correct Answer: 2. Sitting up for a few minutes before standing to minimize
orthostatic hypotension
68) One day after being admitted with bipolar disorder, a client becomes
verbally aggressive during a group therapy session. Which response bythe
nurse would be therapeutic?
1. “You’re behaving in an unacceptable manner, and you need to control
yourself.”
2. “If you continue to talk like that, no one will want to be around you.”
3. “You’re disturbing the other clients. I’ll walk with you around the patio to
help you release some of your energy.”
4. “You’re scaring everyone in the group. Leave the room immediately.”
Correct Answer: 3 “You’re disturbing the other clients. I’ll walk with you around
the patio to help you release some of your energy.”
69) A client comes to the emergency department complaining of headache,
malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a
temperature elevation, increased heart and respiratory rates, and normal blood
pressure. Onphysical examination, the nurse notes confusion, a petechial rash,
nuchal rigidity, Brudzinski’s sign, and Kernig’s sign. What does Brudzinski’s
sign indicate?
1. Increased intracranial pressure (ICP)
2. Cerebral edema
3. Low cerebrospinal fluid (CSF) pressure
4. Meningeal irritation
Correct Answer: 4. Meningeal irritation
70) During a routine examination, the nurse notes that the client seems
unusually anxious. Anxiety can affect the genitourinary system by:
1. slowing the glomerular filtration rate.
2. increasing sodium resorption.
3. decreasing potassium excretion.
4. stimulating or hindering micturition.
Correct Answer: 4. stimulating or hindering micturition.
71) The nurse is advising a mother about foods to avoid to prevent choking in
her toddler. Which foods should she include inher instruction?
1. Small pieces of banana
2. Large, round chunks of meat such as hot dog
3. Cooked vegetables such as lima beans and corn
4. Frozen desserts such as ice cream
Correct Answer: 2. Large, round chunks of meat such as hot dog
72) A client with a history of Addison’s disease and flulike symptoms
accompanied bynausea and vomiting overthe past week isbrought tothe
facility. The client’s wife reports that she noticed that he acted confused and
was extremely weak when he woke up in the morning. The client’s blood
pressure is90/58 mmHg, his pulse is 116beats/minute, and his temperature is
101° F (38.3° C). A diagnosis ofacute adrenal insufficiency ismade. Which
of the following would the nurse expect to administer by I.V. infusion?
1. Insulin
2. Hydrocortisone
3. Potassium
4. Hypotonic saline
Correct Answer: 2. Hydrocortisone
73) A toddler is diagnosed with a dislocated right shoulder and a simple
fracture ofthe right humerus. Which behavior most strongly suggests that the
child’s injuries stem from abuse?
1. Trying to sit up on the stretcher
2. Trying to move away from the nurse
3. Not answering the nurse’s questions
4. Not crying when moved
Correct Answer: 4Not crying when moved
74) A client is scheduled for an excretory urography at 10 a.m. An order states
to insert a saline lock I.V. device at 9:30 a.m.. The client requests a local
anesthetic for the I.V. procedure and the physician orders lidocaine-prilocaine
cream (EMLA cream). The nurse should apply the cream at:
1. 7:30 a.m.
2. 6:30 a.m.
3. 9 a.m.
4. 9:30 a.m.
Correct Answer: 1 7:30 a.m.
75) Which nursing action is essential when providing continuous enteral
feeding?
1. Elevating the head of the bed at least 30 degrees
2. Positioning the client on the left side
3. Warming the formula before administering it
4. Hanging a full day’s worth of formula at one time
Correct Answer: 1. Elevating the head of the bed at least 30 degrees
76) When taking a dietary history from a newly admitted client, the nurse
should remember that which ofthe following foods isa common allergen?
1. Bread
2. Carrots
3. Oranges
4. Strawberries
Correct Answer: 4. Strawberries
77) The physician prescribes furosemide (Lasix), 2 mg/kg P.O., as a one-time
dose for aninfant with fluid overload. The infant’s documented weight is 14
lb. The oral solution contains 10mg/ml. How many milliliters ofsolution
should the nurse administer?
Correct Answer: 1.3
78) For a client with Graves’ disease, which nursing intervention promotes
comfort?
1. Restricting intake of oral fluids
2. Placing extra blankets on the client’s bed
3. Limiting intake of high-carbohydrate foods
4. Maintaining room temperature in the low-normal range
Correct Answer: 4. Maintaining room temperature in the low-normal range
79) A client is admitted with a diagnosis of delusions of grandeur. This
diagnosis reflects a belief that he is:
1. highly important or famous.
2. being persecuted.
3. connected to events unrelated to himself.
4. responsible for the evil in the world.
Correct Answer: 1. highly important or famous.
80) A toddler is having a tonic-clonic seizure. What should the nurse do first?
1. Restrain the child.
2. Place a tongue blade in the child’s mouth.
3. Remove objects from the child’s surroundings.
4. Check the child’s breathing.
Correct Answer: 3. Remove objects from the child’s surroundings.
81) A 40-year-old client is admitted to the hospital for alcohol abuse for the
third time inthe past 9 months. The health care team recommends
rehabilitative treatment for this client. Whywas this treatment recommended?
1. It’s the only option for controlling alcohol consumption.
2. It helps the client identify a new group of friends.
3. It helps the client understand the effects of alcohol on his body.
4. It helps the client identify the relationship between his problems and alcohol
consumption.
Correct Answer: 4 It helps the client identify the relationship between his
problems and alcohol consumption.
82) A man at a pizza parlor verbally confronts the waiter for lack of
attentiveness. Later, inthe back room, the waiter spits onthe man’s pizza. This
is an example of a behavior typical of which disorder?
1. Obsessive-compulsive
2. Narcissistic
3. Passive-aggressive
4. Dependent
Correct Answer: 3Passive-aggressive
83) A client with end-stage acquired immunodeficiency syndrome (AIDS) has
profound manifestations of Cryptosporidium infection caused by the protozoa.
In planning the client’s care, the nurse should focus on his need for:
1. pain management.
2. fluid replacement.
3. antiretroviral therapy.
4. high-calorie nutrition.
Correct Answer: 2 fluid replacement.
84) Following a small-bowel resection, a client develops fever and anemia.
The surface surrounding the surgical wound is warm tothe touch and
necrotizing fasciitis issuspected. Another manifestation that would most
suggest necrotizing fasciitis is:
1. erythema.
2. leukocytosis.
3. pressure like pain.
4. swelling.
Correct Answer: 3 pressure like pain.
85) A 42-year-old client comes to the clinic and is diagnosed with shingles.
Which findings confirm this diagnosis?
Select all that apply:
1. Severe, deep pain around the thorax
2. Red, nodular skin lesions around the thorax
3. Fever
4. Malaise
5. Diarrhea
Correct Answer: 1,2,3,4
86) A newly hired licensed practical nurse (LPN) is helping the charge nurse
admit a client. The charge nurse asks the LPN ifshe understands the facility’s
rules ofethical conduct. Which statement bythe LPN indicates the need for
further teaching?
1. “I make sure that I do everything in my client’s best interest.”
2. “I maintain client confidentiality at all times.”
3. “I always support the Patient’s Bill of Rights.”
4. “I don’t discuss advance directives unless the client initiates the
conversation.”
Correct Answer: 4 “I don’t discuss advance directives unless the client initiates
the conversation.”
87) Which safety device is most restrictive for a client with dementia?
1. Walker
2. Childproof locks on cabinets and doors
3. Electronic monitoring system
4. Lap tray placed on a wheelchair
Correct Answer: 4. Lap tray placed on a wheelchair
88) The nurse is teaching parents how to reduce the spread of impetigo. The
nurse should encourage parents to:
1. teach children to cover mouths and noses when they sneeze.
2. have their children immunized against impetigo.
3. teach children the importance of proper hand washing.
4. isolate the child with impetigo from other members of the family.
Correct Answer: 3 teach children the importance of proper hand washing.
89) A diabetic client develops sinusitis and otitis media accompanied by a
temperature of100.8° F (38.2° C). What effect may these findings haveonhis
need for insulin?
1. They will have no effect.
2. They will decrease the need for insulin.
3. They will increase the need for insulin.
4. They will cause wide fluctuations in the need for insulin.
Correct Answer: 3 They will increase the need for insulin.
90) A school-age child with terminal leukemia is admitted to the pediatric
unit. The nurse must discuss advance directives with the child’s parents. The
nurse should include which information?
1. Positive appraisal of the child’s prognosis
2. Chemotherapy options
3. Comfort care options
4. Bone marrow transplantation information
Correct Answer: 3 Comfort care options
91) A client is scheduled for surgery under general anesthesia. The night
before surgery, the client tells the nurse, “I can’t wait tohave breakfast
tomorrow.” Based onthis statement, the nurse should formulate which nursing
diagnosis?
1. Deficient knowledge related to food restrictions associated with anesthesia
2. Fear related to surgery
3. Risk for impaired skin integrity related to upcoming surgery
4. Ineffective coping related to the stress of surgery
Correct Answer: 1 Deficient knowledge related to food restrictions associated
with anesthesia
92) The nurse is caring for a client with skin grafts covering third-degree
burns onthe arms and legs. During dressing changes, the nurse should besure
to:
1. apply maximum bandages to allow for absorption of drainage.
2. wrap elastic bandages distally to proximally on dependent areas.
3. wrap elastic bandages on the arms and legs, proximally to distally, to
promote venous return.
4. put on sterile gloves only when removing bandages.
Correct Answer: 2. wrap elastic bandages distally to proximally on dependent
areas.
93) A client with hyperemesis gravidarum is on a clear liquid diet. The nurse
should serve this client:
1. milk and ice pops.
2. decaffeinated coffee and scrambled eggs.
3. tea and gelatin dessert.
4. apple juice and oatmeal.
Correct Answer: 3tea and gelatin dessert.
94) Because of difficulties with hemodialysis, peritoneal dialysis is initiated to
treat a client’s uremia. Which finding signals a significant problem during this
procedure?
1. Blood glucose level of 200 mg/dl
2. White blood cell (WBC) count of 20,000/mm3
3. Potassium level of 3.8 mEq/L
4. Hematocrit (HCT) of 35%
Correct Answer: 2 White blood cell (WBC) count of 20,000/mm3
95) The nurse is collecting data on an 8-month-old infant during a wellness
checkup. Which ofthe following isa normal developmental task for aninfant
this age?
1. Sitting without support
2. Saying two words
3. Feeding himself with a spoon
4. Playing patty-cake
Correct Answer: 1. Sitting without support
96) The nurse is caring for a client with tuberculosis. Which precautions
should the nurse take when providing care for this client?
Select all that apply:
1. Wear gloves when handling tissues containing sputum.
2. Wear a face mask at all times.
3. Keep the client in strict isolation.
4. When the client leaves the room for tests, have all people in contact with
him wear a mask.
5. Keep the client’s door open to allow fresh air into room and prevent social
isolation.
6. Wash hands after direct contact with the client or contaminated articles.
Correct Answer: 1,2,6
97) A client with moderate pregnancy-induced hypertension (PIH) is a poor
candidate for regional anesthesia during labor and delivery. Ifshe were to
receive this form of anesthesia, she might experience:
1. hypotension.
2. hypertension.
3. seizures.
4. renal toxicity.
Correct Answer: 1 hypotension.
98) A postpartum client requires teaching about breast-feeding. To prevent
breast engorgement, the nurse should instruct her to:
1. use an electric breast pump.
2. apply warm, moist compresses to the breasts.
3. breast-feed every 1½ to 3 hours.
4. wear a brassiere 24 hours per day.
Correct Answer: 3 breast-feed every 1½ to 3 hours.
99) A client with chronic renal failure has a serum potassium level of 6.8
mEq/L. What should the nurse assess first?
1. Blood pressure
2. Respirations
3. Temperature
4. Cardiac rhythm
Correct Answer: 4 Cardiac rhythm
100) A client asks the nurse, “Do you think I should leave my husband?” The
nurse responds, “You aren’t sure ifyou should leave your husband?” The nurse
is using which therapeutic technique?
1. Restating
2. Reframing
3. Reflecting
4. Offering a general lead
Correct Answer: 3Reflecting
101) The nurse is teaching a client about malabsorption syndrome and its
treatment. The client asks which part ofthe GItractabsorbs food. The nurse
tells the client that products of digestion are absorbed mainly inthe:
1. stomach.
2. small intestine.
3. large intestine.
4. rectum.
Correct Answer: 2 small intestine.
102) Which interventions are appropriate when caring for a client with acute
thrombophlebitis?
1. Apply cool soaks and keep the client’s leg lower than the level of the heart.
2. Increase the client’s activity level and encourage leg exercises.
3. Apply cool soaks and administer nitroglycerin.
4. Apply warm soaks and elevate the client’s legs higher than the level of the
heart.
Correct Answer: 4 Apply warm soaks and elevate the client’s legs higher than
the level of the heart.
103) Damage to which area of the brain results in receptive aphasia?
1. Parietal lobe
2. Occipital lobe
3. Temporal lobe
4. Frontal lobe
Correct Answer: 3 Temporal lobe
104) A client with Alzheimer’s disease mumbles incoherently and rambles in a
confused manner. Tohelp redirectthe client’s attention, the nurse should
encourage the client to:
1. fold towels and pillowcases.
2. play cards with another client.
3. participate in a game of charades.
4. perform an aerobic exercise.
Correct Answer: 1 . fold towels and pillowcases.
105) The nurse is caring for a 16-year-old pregnant client who is taking an
iron supplement. Which instruction should the nurse include when teaching
the adolescent about ferrous sulfate?
Select all that apply:
1. Take the supplement with food.
2. Report black stools to the physician immediately.
3. Avoid taking the supplement with milk.
4. Avoid taking the supplement with antacids.
5. Avoid chewing the extended-release form of the drug.
Correct Answer: 3,4,5
106) A 76-year-old client is admitted to a long-term care facility with
Alzheimer’s-type dementia. The client has been wearing the same dirty clothes
for several days. The nurse contacts the family and asks them tobring inclean
clothing. Which intervention would best prevent further regression inthe
client’s personal hygiene?
1. Encouraging the client to perform as much self-care as possible
2. Making the client assume responsibility for physical care
3. Assigning a staff member to take over the client’s physical care
4. Accepting the client’s desire to go without bathing
Correct Answer: 1.Encouraging the client toperform asmuch self-care aspossible
107) A client, age 20, is being treated for depression. During a conversation
with the nurse, she states that her father raped her when she was 7 years old.
She says she has nightmares about the experience and sometimes relives it.
She also reveals that she fears older men. The client may beexhibiting signs
of:
1. post traumatic stress disorder (PTSD), delayed onset.
2. multiple personality disorder.
3. anxiety disorder.
4. schizophrenia.
Correct Answer: 1 post traumatic stress disorder (PTSD), delayed onset.
108) In a client who’s predisposed to bipolar disorder, a bipolar episode might
be triggered by:
1. hypothyroidism.
2. hyperglycemia.
3. hypertension.
4. antiseizure medication.
Correct Answer: 1 hypothyroidism.
109) One aspect of implementation related to drug therapy is:
1. developing a content outline.
2. documenting drugs given.
3. establishing outcome criteria.
4. setting realistic client goals.
Correct Answer: 2 documenting drugs given.
110) A client who sustained an L1 to L2 spinal cord injury in a construction
accident asks a nurse ifhe’ll ever beable towalk again. Which response bythe
nurse is appropriate?
1. “If you keep a positive attitude, you can do anything.”
2. “What makes you think you won’t be able to walk again?”
3. “What has your physician told you about your ability to walk again?”
4. “Most likely you won’t be able to, but we never know for sure.”
Correct Answer: 3 . “What has your physician told you about your ability to
walk again?”
111) While obtaining a health history, the nurse learns that the client is allergic
to bee stings. When obtaining this client’s medication history, the nurse should
determine if the client keeps which medication on hand?
1. diphenhydramine hydrochloride (Benadryl)
2. pseudoephedrine hydrochloride (Sudafed)
3. guaifenesin (Robitussin)
4. loperamide (Imodium)
Correct Answer: 1 diphenhydramine hydrochloride (Benadryl)
112) The nurse is caring for a client with delirium. Which of the following is
most important for the nurse to provide the client?
1. A safe environment
2. An opportunity to release frustration
3. Prescribed medications
4. Medications as needed, judiciously
Correct Answer: 1 A safe environment
113) The surgeon is discussing surgery with a client diagnosed with colon
cancer. The client isvisibly shaken over the possibility ofacolostomy. Based
on the client’s response, the surgeon should collaborate with which health
team member?
1. Social worker
2. Staff nurse
3. Clinical educator
4. Enterostomal nurse
Correct Answer: 4 Enterostomal nurse
114) A client, age 21, is admitted with bacterial meningitis. Which hospital
room would be the appropriate choice for this client?
1. A private room down the hall from the nurses’ station
2. An isolation room close to the nurses’ station
3. A semiprivate room with a 32-year-old client who has viral meningitis
4. A two-bed room with a client who previously had bacterial meningitis
Correct Answer: 2 An isolation room close to the nurses’ station
115) Which psychological or personality factor is likely to predispose an
individual to medication abuse?
1. Low self-esteem and unresolved rage
2. Desire to inflict pain upon one’s self
3. Dependent personality disorder
4. Antisocial personality disorder
Correct Answer: 1 Low self-esteem and unresolved rage
116) Which detail of a client’s drug therapy is the nurse legally responsible for
documenting?
1. Peak concentration time of the drug
2. Safe ranges of the drug
3. Client’s socioeconomic data
4. Client’s reaction to the drug
Correct Answer: 4 Client’s reaction to the drug
117) The nurse is performing a neurologic assessment on a 1-day-old neonate.
Which ofthe following findings would indicate possible asphyxia inutero?
Select all that apply:
1. The neonate grasps the nurse’s finger when she puts it in the palm of his
hand.
2. The neonate does stepping movements when held upright with his sole
touching a surface.
3. The neonate’s toes don’t curl downward when his soles are stroked.
4. The neonate doesn’t respond when the nurse claps her hands above him.
5. The neonate turns toward an object when the nurse touches his cheek with
it.
6. The neonate displays weak, ineffective sucking.
Correct Answer: 3,4,6
118) The mother of a 3-year-old has been told that her child has a brain tumor.
She initially begins tocry and accuses the physicians oflying. Which ofthe
following stages isthe mother most likely experiencing?
1. Acceptance
2. Psychotic episode
3. Anger
4. Denial
Correct Answer: 3 Anger
119) A client with pregnancy-induced hypertension (PIH) receives magnesium
sulfate, 4 g in50% solution I.V. over 20minutes. What is the purpose of
administering magnesium sulfate to this client?
1. To lower blood pressure
2. To prevent seizures
3. To inhibit labor
4. To block dopamine receptors
Correct Answer: 2 To prevent seizures
120) The nurse assesses a client who gave birth 24 hours earlier. Which of the
following findings reveals the need for further evaluation?
1. Chills
2. Scant lochia rubra
3. Thirst and fatigue
4. Temperature of 100.2° F (37.9° C)
Correct Answer: 2 Scant lochia rubra
121) A client with chronic obstructive pulmonary disease, who has been
receiving mechanical ventilation for the past 5 days, expresses toa nurse his
desire tohave treatment withdrawn. Which statement about the client’s legal
rights is true in this situation?
1. The nurse’s assessment of the client and communication with the family
guides the decision-making process.
2. The nurse is an advocate for the client and should encourage the client to
accept his current treatment regimen.
3. The health care team must follow the treatment plan that was already
established with client and family input.
4. The client has the right to refuse treatment at any time.
Correct Answer: 4 The client has the right to refuse treatment at any time.
122) A client with newly diagnosed breast cancer asks the nurse, “Why me?
I’ve always been a good person. What have I done todeserve this?” Which
response by the nurse would be most therapeutic?
1. “Don’t worry. You’ll probably live longer than I will.”
2. “I’m sure a cure will be found soon.”
3. “You seem upset. Let’s talk about something happy.”
4. “Would you like to talk about this?”
Correct Answer: 4 “Would you like to talk about this?”
123) The mother of a 3-year-old child is complaining that her son still throws
temper tantrums when hedoesn’t get his way. How should the nurse advise the
mother to respond?
1. Tell the mother to ignore the child because eventually he will stop having
temper tantrums.
2. Tell the mother to promise him a new toy if he stops the tantrum.
3. Tell the mother to give in to his demands; he is only 3-years-old.
4. Tell the mother to mimic him so that he can see what his behavior looks
like.
Correct Answer: 1 Tell the mother to ignore the child because eventually he will
stop having temper tantrums.
124) A client asks the nurse about the rhythm (calendar-basal body
temperature) method offamily planning. The nurse explains that this method
involves:
1. chemical barriers that act as spermicidal agents.
2. hormones that prevent ovulation.
3. mechanical barriers that prevent sperm from reaching the cervix.
4. determination of the fertile period to identify safe times for sexual
intercourse.
Correct Answer: 4 determination of the fertile period to identify safe times for
sexual intercourse.
125) The nurse-manager overhears a nurse tell a client, “If I were you, I’d ask
the doctor for something for pain; you shouldn’t have to suffer during labor.”
How should the nurse-manager respond tothe nurse’s comment?
1. Don’t respond because the nurse’s statement is correct.
2. Confront the nurse in the client’s room and remind her that it’s inappropriate
to administer pain medications to clients in labor.
3. Inform the nurse that she’d like to speak with her, then discuss the
inappropriateness of her comment ina private location.
4. Notify the physician of the client’s pain and request that he prescribe pain
medication for the client.
Correct Answer: 3 Inform the nurse that she’d like to speak with her, then
discuss the inappropriateness of her comment ina private location.
126) A client is receiving an I.V. infusion of mannitol (Osmitrol) after
undergoing intracranial surgery toremove a brain tumor. Todetermine
whether this drug isproducing itstherapeutic effect, the nurse should consider
which finding the most significant?
1. Decreased level of consciousness (LOC)
2. Elevated blood pressure
3. Increased urine output
4. Decreased heart rate
Correct Answer: 3 Increased urine output
127) A hospitalized client asks the nurse for “something for pain.” Which
information ismost important for the nurse togather before administering the
medication?
Select all that apply:
1. Administration time of the last dose
2. Client’s pain level on a scale of 1 to 10
3. Type of medication the client has been taking
4. Client’s reaction to the previous dose
5. Client’s most current height and weight
6. Effectiveness of prior dose of medication
Correct Answer: 1,2,3,4,6
128) The nurse collects data on a client shortly after kidney transplant surgery.
Which postoperative finding must the nurse report to the physician
immediately?
1. Serum potassium level of 4.9 mEq/L
2. Serum sodium level of 135 mEq/L
3. Temperature of 99.2° F (37.3° C)
4. Urine output of 20 ml/hour
Correct Answer: 4 Urine output of 20 ml/hour
129) A client receiving total parental nutrition is prescribed a 24-hour urine
test. When initiating a 24-hour urine specimen, the collection time should:
1. start with the first voiding.
2. start after a known voiding that empties the bladder.
3. always be with first morning urine.
4. always be the last evening’s void as the last sample.
Correct Answer: 2 start after a known voiding that empties the bladder.
130) A client is receiving nitroglycerin ointment (Nitrol) to treat angina
pectoris. The nurse evaluates the therapeutic effectiveness ofthis drug by
assessing the client’s response and checking for adverse effects. Which vital
sign ismost likely toreflect an adverse effect of nitroglycerin?
1. Heart rate
2. Respiratory rate
3. Blood pressure
4. Temperature
Correct Answer: 3 Blood pressure
131) Which drugs may be abused because of tolerance and physiologic
dependence?
1. Lithium (Lithobid) and divalproex (Depakote).
2. Verapamil (Calan) and chlorpromazine (Thorazine)
3. Alprazolam (Xanax) and phenobarbital (Luminal)
4. Clozapine (Clozaril) and amitriptyline (Elavil)
Correct Answer: 3 Alprazolam (Xanax) and phenobarbital (Luminal)
132) When collecting data on a neonate, the nurse observes a vaguely outlined
area of scalp edema. Which term should the nurse use when documenting this
observation?
1. Cephalhematoma
2. Petechiae
3. Subdural hematoma
4. Caput succedaneum
Correct Answer: 4 Caput succedaneum
133) A 50-year-old male client is hospitalized in a psychiatric unit for treatment of
an acute phase of paranoid schizophrenia with delusions of persecution. At the end
of her shift, a licensed practical nurse reports the client’s status to a registered
nurse. Which observation bythe licensed practical nurse indicates that the client’s
condition isimproving?
1. The client sits and stares at the television for several hours.
2. After shaving and showering, the client reports that the voices have been quiet
for several days.
3. The client reports that the television transmits thoughts to his mind less
frequently than it did before.
4. The client searches his room for hidden transmitters.
Correct Answer: 2 After shaving and showering, the client reports that the voices
have been quiet for several days.
134) For a child who’s admitted to the emergency department with an acute
asthma attack, nursing data collection is most likely to reveal:
1. apneic periods.
2. expiratory wheezing.
3. inspiratory stridor.
4. absent breath sounds.
Correct Answer: 2 expiratory wheezing.
135) The physician diagnoses leukemia in a child, age 4, who complains of
being tired and sleepsmost of the day. Which nursing diagnosis reflects the
nurse’s understanding ofthe pathophysiology behind leukemia?
1. Ineffective airway clearance related to fatigue
2. Activity intolerance related to anemia
3. Imbalanced nutrition: More than body requirements related to lack of activity
4. Ineffective cerebral tissue perfusion related to central nervous system
infiltration byleukemic cells
Correct Answer: 2 Activity intolerance related to anemia
136) The nurse is collecting data on a 38-year-old client diagnosed with
multiple sclerosis. Which ofthe following symptoms would the nurse expect
to find?
1. Vision changes
2. Absent deep tendon reflexes
3. Tremors at rest
4. Flaccid muscles
Correct Answer: 1 Vision changes
137) A client who returned from a cystoscopic examination complains of pain
while attempting tovoid. Which intervention should a nurse suggest toease
the client’s pain while attempting to void?
1. Drink plenty of fluids.
2. Pour water over the perineal area.
3. Run water in the bathroom sink.
4. Sit in a warm sitz bath.
Correct Answer: 4Sit in a warm sitz bath.
138) A client has a nursing diagnosis of Risk for injury related to adverse effects
of potassium-wasting diuretics. What is a correctly written client outcome for
this nursing diagnosis?
1. “Before discharge, the client correctly identifies three potassium-rich food
sources.”
2. “The client knows the importance of consuming potassium-rich foods daily.”
3. “Before discharge, the client knows which food sources are high in
potassium.”
4. “The client understands all complications of the disease process.”
Correct Answer: 1 “Before discharge, the client correctly identifies three
potassium-rich food sources.”
139) To minimize the amount of a drug received by an infant through breast-
feeding, the nurse should tell the mother to:
1. take the medication immediately before breast-feeding.
2. take the medication immediately after breast-feeding.
3. feed the infant 2 hours after taking the medication.
4. feed the infant 4 hours after taking the medication.
Correct Answer: 2 take the medication immediately after breast-feeding.
140) Which task can the licensed practical nurse (LPN) appropriately delegate
to the nursing assistant?
1. Obtaining vital signs on a client who has just returned from undergoing a
colonoscopy
2. Feeding a client for the first time after he has experienced a stroke
3. Administering feedings through a nasogastric tube
4. Encouraging a client to drink fluids
Correct Answer: 4 Encouraging a client to drink fluids
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A client being treated for hypertension returns to the community clinic for follow up. The client says, “I know these pills are important, but I just can’t take these water pills anymore. I drive a truck for a living, and I can’t be stopping every 20 minutes to go to the bathroom.” Which of these is the best nursing diagnosis?A) Noncompliance related to medication side effectsB)Knowledge deficit related to misunderstanding of disease stateC)Defensive coping related to chronic illnessD) Altered health maintenance related to occupationThe correct answer is A: Noncompliance related to medication side effectsWhen teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?A) BiofeedbackB)Deep breathingC)DistractionD) ImageryPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is B: Deep breathingWhen observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in?A) Competitive board games with older childrenB)Playing with their own toys along side with other childrenC)Playing alone with hand held computer gamesD) Playing cooperatively with other preschoolersThe correct answer is D: Playing cooperatively with other preschoolersThe nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?A) Hold a rattleB)Bang two blocksPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)Drink from a cupD) Wave “bye-bye”The correct answer is A: Hold a rattleWhen teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs ofthis age child?A) Provide a verbal explanation just prior to the surgeryB)Provide the child with a booklet to read about the surgeryC)Introduce the child to another child who had heart surgery 3 days agoD) Explain the surgery using a model of the heartThe correct answer is D: Explain the surgery using a model of the heartThe parents of a child who has suddenly been hospitalized for an acuteillness state that they should have taken the child to the pediatrician earlier.Which approach by the nurse is best when dealing with the parents’comments?PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A) Focus on the child’s needs and recoveryB)Explain the cause of the child’s illnessC)Acknowledge that early care would have been betterD) Accept their feelings without judgmentThe correct answer is D: Accept their feelings without judgmentWhen caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse?A) Record the number of stools per dayB)Maintain strict intake and output recordsC)Sterile technique for dressing change at IV siteD) Monitor for cardiac arrhythmiasThe correct answer is C: Sterile technique for dressing change at IV sitePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023When caring for a client who is receiving a thrombolytic agent to open a clot occluded coronary artery after a myocardial infarction, which finding would be of greatest concern to the nurse?A) Sero sanginous drainage from gumsB)HematemesisC)Pink frothy sputumD) Slight red color at urineThe correct answer is B: HematemesisA 52 year-old client is being transfused with one unit of packed cells. A half hour after the transfusion was initiated, the client complains of chills and headache. Which action should the nurse implement first?A) Notify the health care providerB)Check the client’s temperatureC)Stop the transfusionPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) Obtain a urine specimenThe correct answer is C: Stop the transfusionAn adolescent client is hospitalized with menarthrosis from a HemophiliaA bleeding episode. Which order should be questioned by the nurse?A) Passive range of motionB)Replacement of factor VIIIC)Aspirin for pain managementD) Immobilization splintThe correct answer is C: Aspirin for pain managementThe nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which statement by the mother would indicate the need forfurther teaching?A) “Nystatin should be given 4 times a day after my baby eats.”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
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PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)”I will boil the nipples and pacifiers for twenty minutes.”C)”I should be taking the medication prescribed for this infection.”D) “The therapy can be discontinued when the spots disappear.”The correct answer is D: “The therapy can be discontinued when the spots disappear.”The nurse is preparing a client for discharge following in-patient treatment for pulmonary tuberculosis. Which of these instructions should be given to the client?A) Continue medication until findings are relievedB)Continue medication use as prescribedC)Avoid contact with children, pregnant women or immune depressed personsD) Take medication with Amphogel if epigastric distress occursThe correct answer is B: Continue medication use as prescribedPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse’s immediate attention?A) “I have a burning sensation when I urinate.”B)”I have soreness and aching in my muscles.”C)”I am itching all over.”D) “I have cramping in my stomach.”The correct answer is C: “I am itching all over.”A woman diagnosed with bipolar disorder is to take lithium (Lithane) as part of the treatment. What should the nurse discuss with the client as part of the teaching plan?A) Risks of oral contraceptivesB)Reduction in exercise programC)Avoidance of alcoholD) Cessation of smokingPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is C: Avoidance of alcoholThe nurse prepares to administer eye drops to a 6 year-old child. Which ofthese demonstrates the correct method for instillation of eye drops?A) Directly on the anterior surface of the eyeballB)In the corner where the lids meetC)Under the upper lid as it is pulled upwardD) In the conjunctival sac as the lower lid is pulled downThe correct answer is D: In the conjunctival sac as the lower lid is pulled downA depressed client is experiencing severe insomnia. The health care provider orders trazadone (Desyrel). The nurse tells the client to expectA) Improvement of acneB)Relief of insomniaPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)Reduced arthritic painD) Less nasal stuffinessThe correct answer is B: Relief of insomniaA client with diabetes has a blood sugar is 306 this morning. After the nurse reports this lab result and the client’s symptoms of excessive hunger and thirst,what would the nurse expect the health care provider to order?A) Orange juiceB)Regular insulinC)NPH InsulinD) Repeat blood sugar levelPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is B: Regular insulinThe nurse is planning to administer otic drops to a 6 year-old child. Which of the following is the correct procedure?A) Hold the pinna up and back to instill the dropsB)Place several drops in the outer earC)Insert cotton in the outer ear after giving medicationD) Assist the child to lie on the affected side afterwardsThe correct answer is A: Hold the pinna up and back to instill the dropsA 1 year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time?A) Use aseptic technique during dressing changesB)Maintain central line catheter integrityPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)Monitor serum glucose levelsD) Check results of liver function testsThe correct answer is C: Monitor serum glucose levelsToday’s prothrombin time for a client receiving Coumadin is 20 (normal range listed by the lab is 10-14). What is the appropriate nursing action?A) Notify the health care provider immediatelyB)Recognize that this is a therapeutic levelC)Observe the client for hematoma developmentD) Assess for bleeding at gums or IV sitesThe correct answer is B: Recognize that this is a therapeutic levelThe nurse administered intravenous gamma globulin to an 18 month-oldchild with AIDS. The parent asks why this medication is being given. What isthe nurse’s best response?PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A) “It will slow down the replication of the virus.”B)”This medication will improve your child’s overall health status.”C)”This medication is used to prevent bacterial infections.”D) “It will increase the effectiveness of the other medications your child receives.”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is C: “This medication is used to prevent bacterial infections.”The nurse is administering the initial total parenteral nutrition solution to a client. Which of the following assessments requires the nurse’s immediate attention?A) Temperature of 37.5 degrees CelsiusB)Urine output of 300 cc in 4 hoursC)Poor skin turgorD) Blood glucose of 350 mg/dlThe correct answer is D: Blood glucose of 350 mg/dlThe nurse is teaching a client with asthma about the correct use of the Azmacort (triamcinolone) inhaler. Which of the following statements, if made by the client, would indicate that the teaching was effective?A) “The inhaler can be used whenever I feel short of breath.”B)”I should rinse my mouth after using the inhaler.”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)”If I forget a dose, I can double up on the next dose.”D) I should not use a spacer with my Azmacort.The correct answer is B: “I should rinse my mouth after using the inhaler.”A client is admitted to the hospital because of heart failure and digoxin toxicity. At home, the client was taking digoxin (Lanoxin) and furosemide (Lasix). Which symptom would the nurse anticipate finding on the initial assessment? *A) Muscle weakness and crampingB)ConfusionC)Blood in the urineD) TinnitisThe correct answer is A: Muscle weakness and crampingPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The nurse admits a client with hypertension who complains of dizziness after taking diltiazem (Cardizem). Which of the following is the most important information for the nurse to assess?A) Schedule for taking medicineB)Daily intake of potassiumC)Activity and rest patternsD) Baseline heart rate Review Information:PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is A: Schedule for taking medicineWhich of the following classifications of medications would be most often used for clients with schizophrenia?A) Anti-depressantsB)Mood stabilizersC)AnxiolyticsD) NeurolepticsThe correct answer is D: NeurolepticsA hospitalized 8 month-old infant is receiving digoxin for the treatment of Tetralogy of Fallot. Prior to administering the next dose of medication, the parent reports that the baby has vomited one time, just after breakfast. The heart rate is 62. What is the initial response of the nurse?A) Give the dose after lunchB)Reduce the next dose by halfPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)Double the next dose *D) Hold the medicationThe correct answer is D: Hold the medicationA child is treated with edetate calcium disodium (Calcium EDTA) for lead poisoning. Which of these should the nurse assess first ?A) Serum potassium levelB)Blood calcium levelC)Urinary outputD) Deep tendon reflexesThe correct answer is C: Urinary outputThe nurse is assessing a client who has taken haldol (Haloperidol) for several months. Which of the following is a side effect of this medication and must be reported immediately to the health care provider?PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A) Muscle flaccidityB)Dystonic reactionC)Mood swingsD) Dry, harsh coughPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is B: Dystonic reactionThe nurse is caring for a client with renal calculi. Which health care provider order would be a priority?A) Morphine sulfate as client controlled analgesiaB)Push oral fluids and keep vein openC)Continuous warm compresses to the flank areaD) Intravenous antibioticsThe correct answer is A: Morphine sulfate as client controlled analgesiaA client with angina has been instructed about the use of sublingual nitroglycerin. Which of the following statements made to the nurse indicates a need for further teaching?A) “I will rest briefly right after taking 1 tablet.”B)”I can take 2-3 tablets at once if I have severe pain.”C)”I’ll call the doctor if pain continues after 3 tablets 5 minutes apart.”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) “I understand that the medication should be kept in the dark bottle.” The correct answer is B: “I can take 2-3 tablets at once if I have severe pain.”The nurse is teaching administration of albuterol inhalation to an adult with asthma. Which of the following demonstrates proper teaching?A) “Use this medication at bedtime to promote rest.”B)”Discontinue the inhalation if you are dizzy.”C)”Inhale this medication after other asthma sprays.”D) “Notify the health care provider if you need the drug more often.”The correct answer is D: “Notify the health care provider if you need the drug more often.”A hospitalized 8 month-old is receiving gentamicin (Cidomycin). In monitoring the infant for drug toxicity, the nurse should review which laboratory results first?PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A) Blood urea nitrogenB)Thyroxin levelsC)Growth hormone levelsD) Platelet countsThe correct answer is A: Blood urea nitrogenPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A client who is receiving chemotherapy through a central line is admitted to the hospital with a diagnosis of sepsis. Which of the following nursing interventions should receive priority?A) Inspect all sites that may serve as entry ports for bacteriaB)Place the client in reverse isolationC)Change the dressing over the site of the central lineD) Restrict contact with persons having known, or recent, infectionsThe correct answer is A: Inspect all sites that may serve as entry ports for bacteriaThe nurse is caring for a client with Parkinson’s disease who has developed hallucinations. Which of the following medications that the client is receiving may have been a contributing factor?A) L-DopaB)CogentinC)BaclofenPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) BenadrylThe correct answer is A: L-DopaThe nurse is caring for a child receiving albuterol (Proventil) for asthma.The parents ask the nurse why their child is receiving this medication. Which explanation is correct?A) decrease the swelling in the airways.” *B)relax the smooth muscles in the airways.”C)reduce the secretions blocking the airways.”D) stimulate the respiratory center in the brain that control respirations.”The correct answer is B: relax the smooth muscles in the airways.”The nurse prepares to give a one year-old child an intramuscular injection. Where is the best site for this injection?A) Deltoid musclePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)Ventrogluteal muscleC)Dorsogluteal muscleD) Vastus lateralis muscleThe correct answer is D: Vastus lateralis musclePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The nurse is administering albuterol (Proventil) to a child with asthma. Which of the following assessments by the nurse indicate the need for an adjustment of the medication?A) Lethargy and fatigueB)Edema is the lower extremitiesC)Apical Pulse of 112D) Temperature of 101 degrees FahrenheitThe correct answer is C: Apical Pulse of 112To which of the following nursing home residents could the nurse safely administer tricyclic antidepressants without questioning the health care provider’s order?A) An 85 year-old male with narrow-angle glaucomaB)An African-American with benign prostatic hypertrophyC)A 65 year-old female with mild hypertensionPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) A Hispanic female with coronary artery diseaseThe correct answer is C: A 65 year-old female with mild hypertensionThe nurse is teaching a client about precautions with Coumadin. The nurse should instruct the client to avoid foods with excessive amounts of which nutrientA) CalciumB)Vitamin KC)IronD) Vitamin EThe correct answer is B: Vitamin KThe nurse is caring for a 15 month-old child with a first episode of otitis media. Which of the following interventions should the nurse include in instructions to the child’s parents?A) Explain that the child should complete the full 5 days of antibioticsPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)Provide them with handout describing care of myringotomy tubesC)Describe the tympanocentesis to detect persistent infectionsD) Emphasize the importance of a return visit after completion of antibioticsThe correct answer is D: Emphasize the importance of a return visit after completion of antibioticsPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The nurse is caring for an 81 year-old client with colorectal cancer. The client’s pain has been managed until now with acetaminophen with codeine. Because of increased pain, intravenous morphine is added. What should the nurse recognize about the validity of this order?A) Inappropriate because of potential respiratory depressionB)Appropriate despite the expected effect of mental confusionC)Inappropriate and demonstrates poor knowledge of pain controlD) Appropriate pain management around-the-clockThe correct answer is D: Appropriate pain management around-the-clockA 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?A) Explain to the client that the dentures must come out as they may get lost or broken in the operating roomB)Ask the client if there are second thoughts about having the procedurePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)Notify the anesthesia department and the surgeon of the client’s refusalD) Ask the client if the preference would be to remove the dentures in the operating room receiving areaThe correct answer is D: Ask the client if the preference would be to remove thedentures in the operating room receiving areaThe nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which form of evaluation would best measure learning?A) Performance on written testsB)Responses to verbal questionsC)Completion of a mailed surveyD) Reported behavioral changesThe correct answer is D: Reported behavioral changesPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The nurse is planning care for an 18 month-old child. Which action should be included in the child’s care?A) Hold and cuddle the child frequentlyB)Encourage the child to feed himself finger foodC)Allow the child to walk independently on the nursing unitPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) Engage the child in games with other childrenThe correct answer is B: Encourage the child to feed himself finger foodA partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains thatA) Such fantasies can gratify unconscious wishes or prepare for anticipated future eventsB)Detaching or dissociating in this way postpones painful feelingsC)This conversion or transferring of a mental conflict to a physical symptom can lead to marital conflictD) To isolate the feelings in this way reduces conflict within the client and with othersThe correct answer is A: Such fantasies can gratify unconscious wishes or prepare for anticipated future eventsAn appropriate goal for a client with anxiety would be toPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A) Ventilate anxious feelings to the nurseB)Establish contact with realityC)Learn self-help techniquesD) Become desensitized to past traumaThe correct answer is C: Learn self-help techniquesWhile the nurse is administering medications to a client, the client states “I do not want to take that medicine today.” Which of the following responses by the nurse would be best?A) “That’s OK, its all right to skip your medication now and then. ” B) “I will have to call your doctor and report this.” C) “Is there a reason why you don’t want to take your medicine?” D) “Do you understand the consequences of refusing your prescribed treatment?”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is C: “Is there a reason why you don’t want to take your medicine?”While caring for a client, the nurse notes a pulsating mass in the client’s peri umbilical area. Which of the following assessments is appropriate for the nurseto perform?A) Measure the length of the massB)Auscultate the massC)Percuss the massPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) Palpate the massThe correct answer is B: Auscultate the massA client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?A) “Good morning. Do you remember where you are?”B)”Hello. My name is Elaine Jones and I am your nurse for today.”C)”How are you today? Remember, you’re in the hospital.”D) “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”The correct answer is D: “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A) Formula or breast milkB)Dilute nonfat dry milkC)Warmed fruit juiceD) Fluoridated tap waterThe correct answer is A: Formula or breast milkThe family of a 6 year-old with a fractured femur asks the nurse if the child’s height will be affected by the injury. Which statement is true concerning long bone fractures in children?A) Growth problems will occur if the fracture involves the periosteumB)Epiphyseal fractures often interrupt a child’s normal growth patternC)Children usually heal very quickly, so growth problems are rareD) Adequate blood supply to the bone prevents growth delay after fracturesPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is B: Epiphyseal fractures often interrupt a child”s normal growth patternThe nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)?A) April 8B)January 15C)February 11PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) December 23The correct answer is D: December 23When screening children for scoliosis, at what time of development would the nurse expect early signs to appear?A) Prenatally on ultrasoundB)In early infancyC)When the child begins to bear weightD) During the preadolescent growth spurtThe correct answer is D: During the preadolescent growth spurtA client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribeddiet. What would be the most appropriate nursing action?A) Discharge the client from home health care related to noncompliancePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)Notify the health care provider of the client’s failure to follow prescribed dietC)Discuss diet with the client to learn the reasons for not following the dietD) Make a referral to Meals-on-WheelsThe correct answer is C: Discuss diet with client to learn the reasons for not following the dietA client states, “People think I’m no good, you know what I mean?” Which of these responses would be most therapeutic?A) “Well people often take their own feelings of inadequacy out on others.”B)”I think you’re good. So you see, there’s one person who likes you.”C)”I’m not sure what you mean. Tell me a bit more about that.”D) “Let’s discuss this to see the reasons to create this impression on people?”The correct answer is C: “I’m not sure what you mean. Tell me a bit more about that.”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023Before administering digoxin (Lanoxin) to a client, which of the following nursing assessments is a priority?A) Auscultate breath soundsB)Check for bowel soundsC)Monitor the heart rateD) Measure the blood pressureThe correct answer is C: Monitor the heart rateWhen teaching a client about the use of sublingual nitroglycerin, the nurse should emphasize that which of these is the most common side effect?A) HeadacheB)Dry mouthC)DepressionPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) AnorexiaThe correct answer is A: HeadacheWhat would the nurse expect to see in a client who is experiencing symptoms of tardive dyskinesia?A) Rapid tongue movementsB)Uncontrolled hand tremors during mealsC)Behavioral changesD) Repetitive slapping movementsThe correct answer is A: Rapid tongue movementsThe nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which of the following must be emphasized?A) Rest in bed for an hour after taking medicationB)Take the medication at the same time each dayPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)Keep the medication bottle in the refrigeratorD) Carry the nitroglycerine with you at all timesThe correct answer is D: Carry the nitroglycerine with you at all timesThe home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client?A) Ask the client and family if they are satisfied with the care givenB)Determine if the home health aide’s care is consistent with the plan of careC)Investigate if the home health aide is prompt and stays an appropriate length of time for careD) Check the documentation of the aide for appropriateness and comprehensivenessThe correct answer is B: Determine if the home health aide is following the plan of carePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The nurse in the same day surgery unit assigns the unlicensed assistive personnel (UAP) to give a 1000 ml soap solution enema (SSE) to a client scheduled for an abdominal hysterectomy. Which statement by the nurse is most appropriate?A) “Administer enemas until the results are clear.”B)”Give 3 enemas before surgery.”C)”Let me know the results of the enema.”D) “Slow the flow of the solution if cramping occurs.”The correct answer is D: “Slow the flow of the solution if cramping occurs.”An RN from the women’s health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse?A) A newly diagnosed client with type 2 diabetes mellitus who is learning footcareB)A client from a motor vehicle accident with an external fixation device on the legPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)A client admitted for a barium swallow after a transient ischemic attackD) A newly admitted client with a diagnosis of pancreatic cancerThe correct answer is B: A motor vehicle accident (MVA) client with an external fixation device on the legWhich client data should the nurse act upon when a home health aide calls the nurse from the client’s home to report these items?A) The client has complaints of not sleeping well for the past week.B)The family wants to discontinue the home meal service, meals on wheels.C)The urine in the urinary catheter bag is of a deeper amber, almost brown color.D) The partner says the client has slower days every other day.The correct answer is C: The urine in the urinary catheter bag is of a deeper amber almost brown color.PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)?A) Ask the client the degree of relief and document the client’s responseB)Decrease the set rate on the pump by 2 ml/minuteC)Check the IV site for drainage and loose tapeD) Assist the client with ambulation and a gown change The correct answer is D: Assist the client with ambulation and a gown changeA practical nurse (PN) from the pediatric unit is assigned to work in a critical care unit. Which client assignment would be appropriate?A) A client admitted with multiple trauma with a history of a newly implantedpacemakerB)A new admission with left-sided weakness from a stroke and mild confusionC)A 53 year-old client diagnosed with cardiac arrest from a suspected myocardial infarctionPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accidentThe correct answer is D: A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accidentA 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which o staff members should the charge nurse assign the client?A) Unlicensed assistive personnel (UAP)B)Senior nursing studentC)PND) RNThe correct answer is D: An RNWhich statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to ambulate a client for the first time after a colon resection?PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A) “Have the client sit on the side of the bed before helping the client to walk.”B)”If the client is dizzy ask the client to take some slow, deep breaths.”C)”Help the client to walk in the room as often as the client wishes.”D) “When you help the client to walk, ask if any pain occurs.”The correct answer is A: “Have the client sit on the side of the bed before helping him/her to walk.”A charge nurse working in a long term care facility is making out assignments. Which assignment to an unlicensed assistive personnel (UAP), if made by the nurse, requires intervention by the supervisor?A) Provide decubitus ulcer care and apply a dry dressingB)Bathe and feed a client on bed restC)Oral suctioning of an unresponsive elderly clientD) Teaching a family intermittent (bolus) feedings via G-tube before dischargePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is D: Teaching a family intermittent (bolus) feedings via G-tube before dischargeA 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?E)Explain to the client that the dentures must come out as they may get lost or broken in the operating roomF)Ask the client if there are second thoughts about having the procedureG) Notify the anesthesia department and the surgeon of the client’s refusalH) Ask the client if the preference would be to remove the dentures in the operating room receiving areaThe correct answer is D: Ask the client if the preference would be to remove thedentures in the operating room receiving areaPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which form of evaluation would best measure learning?E)Performance on written testsF)Responses to verbal questionsG) Completion of a mailed surveyH) Reported behavioral changesThe correct answer is D: Reported behavioral changesThe nurse is planning care for an 18 month-old child. Which action should be included in the child’s care?E)Hold and cuddle the child frequentlyF)Encourage the child to feed himself finger foodG) Allow the child to walk independently on the nursing unitH) Engage the child in games with other childrenPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is B: Encourage the child to feed himself finger foodA partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains thatE)Such fantasies can gratify unconscious wishes or prepare for anticipated future eventsF)Detaching or dissociating in this way postpones painful feelingsG) This conversion or transferring of a mental conflict to a physical symptom can lead to marital conflictH) To isolate the feelings in this way reduces conflict within the client and with othersThe correct answer is A: Such fantasies can gratify unconscious wishes or prepare for anticipated future eventsAn appropriate goal for a client with anxiety would be toE)Ventilate anxious feelings to the nursePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023F)Establish contact with realityG) Learn self-help techniquesH) Become desensitized to past traumaThe correct answer is C: Learn self-help techniquesWhile the nurse is administering medications to a client, the client states “I do not want to take that medicine today.” Which of the following responses by the nurse would be best?A) “That’s OK, its all right to skip your medication now and then. ” B) “I will have to call your doctor and report this.” C) “Is there a reason why you don’t want to take your medicine?” D) “Do you understand the consequences of refusing your prescribed treatment?”The correct answer is C: “Is there a reason why you don’t want to take your medicine?”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023While caring for a client, the nurse notes a pulsating mass in the client’s peri umbilical area. Which of the following assessments is appropriate for the nurseto perform?E)Measure the length of the massF)Auscultate the massG) Percuss the massPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023H) Palpate the massThe correct answer is B: Auscultate the massA client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?E)”Good morning. Do you remember where you are?”F)”Hello. My name is Elaine Jones and I am your nurse for today.”G) “How are you today? Remember, you’re in the hospital.”H) “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”The correct answer is D: “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023E)Formula or breast milkF)Dilute nonfat dry milkG) Warmed fruit juiceH) Fluoridated tap waterThe correct answer is A: Formula or breast milkThe family of a 6 year-old with a fractured femur asks the nurse if the child’s height will be affected by the injury. Which statement is true concerning long bone fractures in children?E)Growth problems will occur if the fracture involves the periosteumF)Epiphyseal fractures often interrupt a child’s normal growth patternG) Children usually heal very quickly, so growth problems are rareH) Adequate blood supply to the bone prevents growth delay after fracturesPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is B: Epiphyseal fractures often interrupt a child”s normal growth patternThe nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)?E)April 8F)January 15G) February 11PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023H) December 23The correct answer is D: December 23When screening children for scoliosis, at what time of development would the nurse expect early signs to appear?E)Prenatally on ultrasoundF)In early infancyG) When the child begins to bear weightH) During the preadolescent growth spurtThe correct answer is D: During the preadolescent growth spurtA client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribeddiet. What would be the most appropriate nursing action?E)Discharge the client from home health care related to noncompliancePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023F)Notify the health care provider of the client’s failure to follow prescribed dietG) Discuss diet with the client to learn the reasons for not following the dietH) Make a referral to Meals-on-WheelsThe correct answer is C: Discuss diet with client to learn the reasons for not following the dietA client states, “People think I’m no good, you know what I mean?” Which of these responses would be most therapeutic?E)”Well people often take their own feelings of inadequacy out on others.”F)”I think you’re good. So you see, there’s one person who likes you.”G) “I’m not sure what you mean. Tell me a bit more about that.”H) “Let’s discuss this to see the reasons to create this impression on people?”The correct answer is C: “I’m not sure what you mean. Tell me a bit more about that.”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)?A) Document skin turgor and color changesB)Test stool for occult blood and urine for glucoseC)Suggest foods high in iron and those easily consumedD) Report mental status changes and the degree of mental clarityThe correct answer is B: Test stool for occult blood and urine for glucoseWhich one of these tasks can be safely delegated to a PN?A) Assess the function of a newly created ileostomyB)Care for a client with a recent complicated double barrel colostomyC)Provide stoma care for a client with a well functioning ostomyD) Teach ostomy care to a client and their family membersPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is C: Provide stoma care for a client with a well functioning ostomy.The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP?A) Report signs of redness overlying a jointB)Monitor the client’s response to ambulatory activityC)Encouragement for the independence in self-careD) Assist the client to transfer from a bed to a chairThe correct answer is B: Monitor the client”s response to ambulatory activityWhich of these clients would be most appropriate to assign to a PN?A) A trauma victim with quadriplegia and a client 1 day post-op radical neck dissectionB)A client with newly diagnosed type 2 diabetes mellitus and a client with a history of AIDS admitted for pneumoniaPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitationD) A client with a history of schizophrenia in alcohol withdrawal and a client with chronic renal failureThe correct answer is C: A client with hemiplegia is fed by a nasogastric tube and client with a lef t leg amputation in rehabilitation.A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)?A) Teach the client how to cough up secretionsB)Changes the tracheostomy trach tiesC)Monitor if client has shortness of breathD) Perform routine tracheostomy dressing careThe correct answer is D: Perform routine tracheostomy dressing carePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023Which of these clients would be appropriate to assign to a PN?A) A trauma victim with multiple lacerations and requires complex dressings.B)An elderly client with cystitis and an indwelling urethral catheter.C)A confused client whose family complains about the nursing care 2 days after surgery.PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) A client admitted for possible transient ischemic attack with unstable neuro signs.The correct answer is B: An elderly client with cystitis and an indwelling urethral catheter.Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP?A) Assist with plans for any clients dischargedB)Provide basic hygiene care to all clients on the unitC)Assess a client after an acute myocardial infarctionD) Gather the vital signs of all clients on the unitThe correct answer is B: Provide basic hygiene care to all clients on the unitPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023During the interview of a prospective employee who just completed theagency orientation, which approach would be the best for the nurse manager to use to assess competence?A) What degree of supervision for basic care do you think you need?B)Let’s review your skills check-list for type and level of skill.C)Are you comfortable working independently?D) What client care tasks or assignments do you prefer?The correct answer is B: Let’s review your skills check-list for type and level of skill.An unlicensed assistive personnel (UAP), who usually works in pediatrics is assigned to work on a medical-surgical unit. Which one of the questions by thecharge nurse would be most appropriate prior to making delegation decisions?A) “How long have you been a UAP?”B)”What type of care did you give in pediatrics?”C)”Do you have your competency checklist that we can review?”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) “How comfortable are you to care for adult clients?”The correct answer is C: “Do you have your competency checklist that we can review?”The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to?A) Practical nurse (PN)B)Registered Nurse (RN)C)Unlicensed assistive personnel (UAP)PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) VolunteerThe correct answer is C: Unlicensed assistive personnel (UAP)The RN delegates the task of taking vital signs of all the clients on the medicalsurgical unit to an unlicensed assistive personnel (UAP). Specific writtenand verbal instructions are given to not take a post-mastectomy client’s blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client’s left arm. Which of these statements is most accurate? A) The RN is accountable for this situation.B)The RN did not delegate appropriately.C)The UAP is covered by the RN’s license.D) The UAP is responsible for following instructions.The correct answer is D: The UAP is responsible for following instructions.As the RN responsible for a client in isolation, which can be delegated to the PN?A) Reinforcement of isolation precautionsPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)Assessment of the client’s attitude about infection controlC)Evaluation of staffs’ compliance with control measuresD) Observation of the client’s total environment for risksThe correct answer is A: Reinforcement of isolation precautionsThe care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)?A) A client with peripheral vascular disease and an ulceration of the lower leg.B)A pre-operative client awaiting adrenalectomy with a history of asthmaC)An elderly client with hypertension and self-reported noncomplianceD) A new admission with a history of transient ischemic attacks and dizzinessThe correct answer is A: A client with peripheral vascular disease and an ulceration of the lower leg.PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The charge nurse on a cardiac step-down unit makes assignments for the team consisting of an RN, a PN, and an unlicensed assistive person. Which client should be assigned to the PN?A) A 49 year-old with new onset atrial fibrillation with a rapid ventricular responseB)A 58 year-old hypertensive with possible angina.C)A 35 year-old scheduled for cardiac catheterization.D) A 65 year-old for discharge after angioplasty and stent placement.PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is B: A 58 year-old hypertensive with possible angina.When walking past a client’s room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention?A) “If we work together we can get all of the client care completed.”B)”Since I am late for lunch, would you do this one client’s glucose test?”C)”This client seems confused, we need to watch monitor closely.”D) “I’ll come back and make the bed after I go to the lab.”The correct answer is B: “Since I am late for lunch, would you do this one client”s glucose test?”A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements?A) I will arrange for a conference with you and the UAP within the next week.PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)I can assure you that I will look into the matter.C)I would like for you to approach the UAP about the problem the next time it occurs.D) I will add this concern to the agenda for the next unit meeting.The correct answer is C: Suggest that the nurse approach the assistant about theproblemA client experiences intense anxiety after the home was destroyed by afire. The client escaped from the fire with only minor injuries. The nurseknows that the most important initial intervention would be to:A) Suggest the client rent an apartment with a sprinkler systemB)Provide a brochure on methods to promote relaxation.C)Determine available community and personal resourcesD) Explore the feelings of grief associated with the lossThe correct answer is C: Determine available community and personal resourcesPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023An elderly client with tuberculosis has difficulty coughing up secretions fora sputum specimen. Which nursing action is appropriate?A) Spray the oropharynx with salineB)Ask the client to drink a warm liquidC)Force fluids for the next 8 hoursD) Raise the head of the bed to at least 45 degreesPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is D: Raise the head of the bed to at least 45 degreesThe nurse is caring for a 16 year-old client with femur fracture14 hours aftersurgery. Assessment findings include tachycardia, increased shortness of breath, a temperature of 100.2 degrees Fahrenheit, complaints of feeling anxious, and oxygen saturation level of 88%. In immediately notifying the provider of these findings, the nurse recognizes the client is at risk forA) compartment syndromeB)atelectasisC)myocardial infarctionD) fatty embolismThe correct answer is D: fatty embolismThe client referred for a mammography questions the nurses about the cancer risks from radiation exposure. What is the appropriate response by the nurse?A) The radiation from a mammography is equivalent to 1 hour of sun exposure.PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)You have nothing to worry about; it is less than tanning in the nude.C)A chest x-ray gives you more radiation exposure.D) Exposure to mammography every 2 years is not dangerous.The correct answer is A: The radiation from a mammography is equivalent to one hour of sun exposure.On admission to the ambulatory surgery unit, the nurse notices the client’s painted finger nails. On reviewing the pre-op orders, the nurse notes that pulse oximetry has been ordered. Which statement by the nurse is appropriate?A) “In order to measure your oxygen level, please remove the polish from at least 2 nails.”B)”If you do not remove all your polish, I will request a needle stick to test oxygen levels.”C)”I am sorry. All your nail polish must go off.”D) “I will ask your provider if we must ruin those beautiful nails.”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is A: “In order to measure your oxygen level, please removethe polish from at least 2 nails.”The nurse is removing a fecal impaction on a 75 year-old client. It is most important that the nurse remember thatA) the procedure be done prior to the bathB)family members should be taught the procedurePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)cardiac dysrhythmias can result during the processD) increased dietary fiber can minimize such problemsThe correct answer is C: cardiac dysrhythmias can result during the processWhen taking the client’s blood pressure (BP), the nurse cannot hear thesounds through the stethoscope. Which action should the nurse take first?A) take the BP again in 2 minutes in the same armB)retake the BP again immediately in the same armC)use an electronic BP cuff on the other armD) check to see if the stethoscope is pluggedThe correct answer is A: take the BP again in 2 minutes in the same armThe client with multiple sclerosis has an order to change the nasogastric tube. To promote safety when removing the tube, the nurse shouldA) ask the client to hold a breathPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)offer sips of waterC)bring the code cart to the bedsideD) empty the tube of all drainageThe correct answer is A: ask the client to hold a breathA client is being discharged home today, and will be taking K-dur 20mEq per day by mouth. The nurse should reinforce that potassium levels will be decreased byA) foods seasoned with salt substituteB)frequent daily snacks of black licoriceC)prescribed potassium-sparing diureticsD) occasional use of a non steroidal anti-inflammatory drug (NSAID)The correct answer is B: frequent daily snacks of black licoricePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A client has just returned from the Post-Anesthesia Care Unit (PACU) to the surgical unit after a cholecystectomy. When initial vital signs are taken the nurse notes a temperature of 94.8 degrees Fahrenheit. Which first nursing action is appropriate?A) Continue to monitor the vital signs as indicatedB)Apply a warm blanket and check the temperature in 10 minutesPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)Ask the PACU nurse more details of what happened in PACUD) Call the health care provider and obtain further orders for warmingThe correct answer is B: Apply a warm blanket and check the temperature in tenminutesThe client with amyotrophic lateral sclerosis is scheduled for 160 ml of enteral feeding as a bolus every 4 hours. Before flushing with water the nurse aspirates the feeding tube contents and gets back 180 ml of feeding. What is the next appropriate nursing action?A) Administer the feeding as orderedB)Hold the next feedingC)Flush with sterile waterD) Discard the undigested feedingThe correct answer is B: Hold the next feedingPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The nurse is inserting a Foley catheter into the bladder of a female adultclient. The nurse slips the catheter into an opening for four-5 inches and nourine is obtained. The most probable reason for this is thatA) there is no urine present in the bladderB)the catheter is in the vaginaC)the catheter is not inserted in far enoughD) the bladder is over distendedThe correct answer is B: the catheter is in the vaginaAfter the death of a client, the family approaches the nurse and requests that a family member be allowed to perform a ritual bath on the deceased prior to moving the body. The appropriate response by the nurse isA) I will have to check on hospital regulations and policies.B)These procedures have to be carried out by our staff.C)Is there anything you need from me to perform the ritual bath?PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) A ritual bath will have to wait until after post-mortem careThe correct answer is C: Is there anything you need from me to perform the ritual bath?The nurse detects blood-tinged fluid leaking from the nose and ears of ahead trauma client. What is the appropriate nursing action?A) Pack the nose and ears with sterile gauzePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)Apply pressure to the injury siteC)Apply bulky, loose dressing to nose and earsD) Apply an ice pack to the back of the neckThe correct answer is C: Apply bulky, loose dressing to nose and earsA nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are complaining. As a change agent, the nurse manager should firstA) Support the planning committee and post the new scheduleB)Explore how the planning committee evaluated barriers to the planC)Design a different approach to deliver care with fewer staffD) Retain the previous staffing pattern for another 6 monthsThe correct answer is B: Explore how the planning committee evaluated barriersto the planPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The nurse is caring for a depressed client with a new prescription for anSSRI antidepressant. In reviewing the admission history and physical, which ofthe following should prompt questions about the safety of this medication?A) History of obesityB)Prescribed use of an MAO inhibitorC)Diagnosis of vascular diseaseD) Takes antacids frequentlyThe correct answer is B: Prescribed use of an MAO inhibitorIn preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?A) Cardizem SR tablet (diltiazem)B)Lanoxin liquidC)Os-cal tablet (calcium carbonate)PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) Tylenol liquid (acetaminophenThe correct answer is A: Cardizem SR tablet (diltiazem)The most common reason for an Apgar score of 8 and 9 in a newborn is anabnormality of what parameter?A) Heart ratePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)Muscle toneC)CryD) ColorThe correct answer is D: Color .A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate initial action?A) Report this immediately to the nurse managerB)Confront the nurse about the suspected drug useC)Sign the narcotic sheet and document the event in an incident reportD) Counsel the colleague about the risky behaviorsThe correct answer is A: Report this immediately to the nurse managerTo obtain data for the nursing assessment, the nurse should:PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A) Observe carefully the client’s nonverbal behaviorsB)Adhere to pre-planned interview goals and structureC)Allow clients to talk about whatever they wantD) Elicit clients’ description of their experiences, thoughts and behaviorsThe correct answer is D: Elicit clients” description of their experiences, thoughts and behaviorsThe nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate?A) Allow the infant to drink the liquid from a medicine cupB)Administer the medication with a syringe next to the tongueC)Mix the medication with the infant’s formula in the bottleD) Hold the child upright and administer the medicine by spoonPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is B: Administer the medication with a syringe next to the tongueA client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by the nurse?A) Suggest isometric exerciseB)Maintain the client on bed restPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)Ambulate for several minutesD) Apply ice to the extremityThe correct answer is B: Maintain the client on bed restThe nurse is teaching diet restrictions for a client with Addison’s disease. The client would indicate an understanding of the diet by statingA) “I will increase sodium and fluids and restrict potassium.”B)”I will increase potassium and sodium and restrict fluids.”C)”I will increase sodium, potassium and fluids.”D) “I will increase fluids and restrict sodium and potassium.”The correct answer is A: “I will increase sodium and fluids and restrict potassium.”A client refuses to take the medication prescribed because the client prefers to take self- prescribed herbal preparations. What is the initial action the nurse should take?PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A) Report the behavior to the charge nurseB)Talk with the client to find out about the preferred herbal preparationC)Contact the client’s health care providerD) Explain the importance of the medication to the clientThe correct answer is B: Talk with the client to find out about the preferred herbal preparationDuring the initial physical assessment on a client who is a Vietnamese immigrant, the nurse notices small, circular, ecchymotic areas on the client’s knees. The best action for the nurse to take is toA) Ask the client for more information about the nature of the bruisesB)Ask the client and then the family about the findingsC)Report the bruising to social services to follow-upD) Document the findings on the admission sheetPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is A: Ask the client for more information about the nature of the bruisesA client with considerable pain asks: “What is your opinion regarding acupuncture as a drug- free method for alleviating pain?” The nurse responds, “I’d forget about it as those weird non- Western treatments can be scary.” The nurse’s response is an example ofA) PrejudiceB)DiscriminationPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)EthnocentrismD) Cultural insensitivityThe correct answer is C: EthnocentrismA 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child’s greatest fear?A) Change in body imageB)An unfamiliar environmentC)Perceived loss of controlD) Guilt over being hospitalizedThe correct answer is C: Perceived loss of controlA nurse arranges for a interpreter to facilitate communication betweenthe health care team and a non-English speaking client. To promotePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023therapeutic communication, the appropriate action for the nurse toremember when working with an interpreter is toA) Promote verbal and nonverbal communication with both the client and the interpreterB)Speak only a few sentences at a time and then pause for a few momentsC)Plan that the encounter will take more time than if the client spoke EnglishD) Ask the client to speak slowly and to look at the person spoken toThe correct answer is A: Promote verbal and nonverbal communication with both the client and the interpreterThe nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age?A) Separation anxietyB)Fear of painC)Loss of controlPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) Bodily injuryThe correct answer is A: Separation anxietyWhich statement describes strategies that help build personal power in an organization? A)Longevity in an organization, social ties to people in power, and a history as someone who does not back down in conflict ends with successB)Goals are met with the use of networking, mentoring, and coalition buildingPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)High visibility and formal power are maintained with a confrontational styleD) Credibility to one’s position is enhanced when professional dress and demeanor are employedThe correct answer is B: Goals are meet with the use of networking, mentoring, and coalition building.A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to haveA) Scrotal discolorationB)Sustained painful erectionC)Inability to achieve erectionD) Heaviness in the affected testicleThe correct answer is D: Heaviness in the affected testiclePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A mother telephones the clinic and says “I am worried because my breast-fed 1 month-old infant has soft, yellow stools after each feeding.” The nurse’s best response would be which of these?A) This type of stool is normal for breast fed infants. Keep doing as you have.B)The stool should have turned to light brown by now. We need to test the stoolC)Formula supplements might need to be added to increase the bulk of the stools.D) Water should be offered several times each day in addition to the breast feeding.The correct answer is A:This type of stool is normal for breast fed infants. Keep doing as you have.Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child’s neck. The parents refuse. The nurse understands that the parents may be concerned aboutA) Mental development delaysPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)Evil eye or envy of othersC)Fright from spiritual beingsD) Balance in body systemsThe correct answer is B: Evil eye or envy of othersWhich statement describes the use of a decision grid for decision making?A) It is both a visual and a quantitative method of decision makingB)It is the fastest way for group decision makingPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)It allows the data to be graphed for easy interpretationD) It is the only truly objective way to make a decision in a groupThe correct answer is A: It is both a visual and a quantitative method of decisionmakingThe nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?A) Massage legs frequentlyB)Frequent turningC)Moisten skin with lotionsD) Apply moist heat to reddened areasThe correct answer is B: Frequent turningDual diagnosis indicates that there is a substance abuse problem as well as aA) Cross addictionPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)Mental disorderC)Disorder of any typeD) Medical problemThe correct answer is B: Mental disorderWhich of the following should the nurse obtain from a client prior to having electroconvulsive therapy?A) Permission to videotapeB)Salivary pHC)Mini-mental status examD) Pre-anesthesia work-upThe correct answer is D: Pre-anesthesia workupPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The nurse is caring for several hospitalized children with the following diagnoses. Which disorder is likely to result in metabolic acidosis?A) Severe diarrhea for 24 hoursB)Nausea with anorexiaC)Alternating constipation and diarrheaD) Vomiting for over 48 hoursPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is A: Severe diarrheaThe nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to removethe nitroglycerine patch after 12 hours in order to prevent what condition?A) Skin irritationB)Drug toleranceC)Severe headachesD) Postural hypotensionThe correct answer is B: Drug toleranceWhat is the major developmental task that the mother must accomplish during the first trimester of pregnancy?A) Acceptance of the pregnancyB)Acceptance of the termination of the pregnancyC)Acceptance of the fetus as a separate and unique beingPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) Satisfactory resolution of fears related to giving birthThe correct answer is A: Acceptance of the pregnancyDuring the two-month well-baby visit, the mother complains that formula seems to stick to her baby’s mouth and tongue. Which of the following would provide the most valuable nursing assessment?A) Inspect the baby’s mouth and throatB)Obtain cultures of the mucous membranesC)Flush both sides of the mouth with normal salineD) Use a soft cloth to attempt to remove the patchesThe correct answer is D: Use a sof t cloth to attempt to remove the patchesAfter successful alcohol detoxification, a client remarked to a friend, “I’ve tried to stop drinking but I just can’t, I can’t even work without having a drink.” The client’s belief that he needs alcohol indicates his dependence is primarilyPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A) PsychologicalB)PhysicalC)BiologicalPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) Social-culturalThe correct answer is A: PsychologicalA nurse is caring for a client with peripheral arterial insufficiency of the lower extremities. Which intervention should be included in the plan of care to reduce leg pain?A) Elevate the legs above the heartB)Increase ingestion of caffeine productsC)Apply cold compressesD) Lower the legs to a dependent positionThe correct answer is D: Lower the legs to a dependent positionA diabetic client asks the nurse why the health care provider ordered a glycolsylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:A) Provides a more precise blood glucose value than self-monitoringPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)Is performed to detect complications of diabetesC)Measures circulating levels of insulinD) Reflects an average blood sugar for several monthsThe correct answer is D: Reflects an average blood sugar for several monthsThe nurse is speaking to a group of parents and school teachers of children about care for children with rheumatic fever. It is a priority to emphasize thatA) Home schooling is preferred to classroom instructionB)Children may remain strep carriers for yearsC)Most play activities will be restricted indefinitelyD) Clumsiness and behavior changes should be reportedThe correct answer is D: Clumsiness and behavior changes should be reportedPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal isA) Avoid alcohol use during this timeB)Observe the client for hypotensionC)Abrupt discontinuation of the drugPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) Assess for mild physical symptomsThe correct answer is A: Avoid alcohol use during this timeA client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the following to prevent aspirintoxicity?A) Serum potassiumB)Protein intakeC)Lactose toleranceD) Serum albuminThe correct answer is D: Serum albuminA mother calls the clinic, concerned that her 5 week-old infant is “sleeping more than her brother did.” What is the best initial response?A) “Do you remember his sleep patterns?”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)”How old is your other child?”C)”Why do you think this a concern?”D) “Does the baby sleep after feeding?”The correct answer is C: “Why do you think this a concern?”The nurse is caring for a client with COPD who becomes dyspneic. The nurseshouldA) Instruct the client to breathe into a paper bagB)Place the client in a high Fowler’s positionC)Assist the client with pursed lip breathingD) Administer oxygen at 6L/minute via nasal cannulaThe correct answer is C: Assist the client with pursed lip breathingThe nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse’s immediate attention?PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A) Temperature of 102 degrees FahrenheitB)Pulse rate of 98 beats per minuteC)Respiratory rate of 32D) Blood pressure of 90/50The correct answer is C: Respiratory rate of 32PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A 6 year-old child diagnosed with acute glomerulonephritis (AGN) is experiencing anorexia, moderate edema and elevated blood urea nitrogen (BUN) levels. The child requests a peanut butter sandwich for lunch. What would the nurse’s best response to this request?A) “That’s a good choice, and I know it is your favorite. You can have it today.”B)”I’m sorry, that is not a good choice, but you could have pasta.”C)”I know that is your favorite, but let me help you pick another lunch.”D) “You cannot have the peanut butter until you are feeling better.”The correct answer is C: “I know that is your favorite, but let me help you pick another lunch.”Which type of traction can the nurse expect to be used on a 7 year-old with a fractured femur and extensive skin damage?A) Ninety-ninetyB)Buck’sC)BryantPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) RussellThe correct answer is A: Ninety-ninetyA nurse aide is taking care of a 2 year-old child with Wilm’s tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?A) “Touching the abdomen could cause cancer cells to spread.”B)”Examining the area would cause difficulty to the child.”C)”Pushing on the stomach might lead to the spread of infection.”D) “Placing any pressure on the abdomen may cause an abnormal experience.”The correct answer is A: “Touching the abdomen could cause cancer cells to spread.”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?A) Gestational age assessment suggested growth retardationB)Meconium was cleared from the airway at deliveryC)Phototherapy was used to treat Rh incompatibilityD) The infant received mechanical ventilation for 2 weeksPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is D: The infant received mechanical ventilation for 2 weeksA client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal isA) “You need to take your medicine, this is how you get well.”B)”If you refuse your medicine, we’ll just have to give you a shot.”C)”What is it about the medicine that you don’t like?”D) “I can see that you are uncomfortable right now, I’ll wait until tomorrow.”The correct answer is C: “What is it about the medicine that you don’t like?”The nurse sees a substance abusing client occasionally in the outpatient clinic. In evaluating the client’s progress, the nurse recognizes that the most revealing resistant behavior isA) Recurring crisesB)Continuing drug useC)Rationalizing commentsPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) Missing appointmentsThe correct answer is B: Continuing drug useA new nurse manager is seeking a mentor in the administrative realm. Which of these characteristics is a priority for the outcome of a positive experience with a mentor?A) Information is clarified as neededB)A teacher-coach role is taken by the mentorC)The mentor accepts feedback objectivelyD) The mentor is randomly assigned by administrationThe correct answer is B: A teacher-coach role is taken by the mentorParents of a 6 month-old breast fed baby ask the nurse about increasing the baby’s diet. Which of the following should be added first?A) CerealPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)EggsC)MeatD) JuiceThe correct answer is A: CerealPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A nurse is eating in the hospital cafeteria when a toddler at a nearby tablechokes on a piece of food and appears slightly blue. The appropriate initial action should be toA) Begin mouth to mouth resuscitationB)Give the child water to help in swallowingC)Perform 5 abdominal thrustsD) Call for the emergency response teamThe correct answer is C: Perform 5 abdominal thrustsA victim of domestic violence states, “If I were better, I would not havebeen beat.” Which feeling best describes what the victim may be experiencing?A) FearB)HelplessnessC)Self-blamePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023D) RejectionThe correct answer is C: Self-blameA client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and complains of being “too sick to return to work.” The client is diagnosed as having somatoform disorder. In formulating a plan of care, the nurse must consider that the client’s behaviorA) Is controlled by their subconscious mindB)Is manipulative to avoid work responsibilitiesC)Would respond to psychoeducational strategiesD) Could be modified through reality therapyThe correct answer is A: Is controlled by their subconscious mindWhich statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child?A) “I know there is a problem since my baby is always constipated.”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)”My child doesn’t like many fruits and vegetables, but she really loves her milk.”C)”I can’t understand why my child is not eating as much as she did 4 months ago.”D) “My child doesn’t drink a whole glass of juice or water at 1 time.”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is B: “My child doesn’t like many fruits and vegetables, but she really loves her milk.”The nurse is planning care for a client during the acute phase of a sickle cell vasoocclusive crisis. Which of the following actions would be most appropriate?A) Fluid restriction 1000cc per dayB)Ambulate in hallway 4 times a dayC)Administer analgesic therapy as orderedD) Encourage increased caloric intakeThe correct answer is C: Administer analgesic therapy as orderedFollowing surgery for placement of a ventriculoperitoneal (VP) shuntas treatment for hydrocephalus, the parents question why the infant hasa small abdominal incision. The best response by the nurse would be to explain that the incision was made in order toA) Pass the catheter into the abdominal cavityPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023B)Place the tubing into the urinary bladderC)Visualize abdominal organs for catheter placementD) Insert the catheter into the stomachThe correct answer is A: Pass the catheter into the abdominal cavityThe nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasizeA) The need for at least 5 servings of dairy products dailyB)Restriction of fluid intake to less than 1 liter per dayC)The importance of walking as much as possibleD) Early recognition of findings associated with tetanyThe correct answer is C: The importance of walking as much as possiblePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A nurse and client are talking about the client’s progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?A) Pre-interactionB)OrientationC)WorkingD) TerminationPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is C: WorkingA child is sent to the school nurse by a teacher who has a written note that Fifth’s disease is suspected. Which characteristic would the nurse expect to find?A) Macule that rapidly progresses to papule and then vesiclesB)Erythema on the face, primarily on cheeks giving a “slapped face” appearanceC)Discrete rose pink macules will appear first on the trunk and fade when pressure is appliedD) Kopeck spots appear first followed by a rash that appears first on the face and spreads downwardThe correct answer is B: Erythema on the face, primarily on cheeks giving a “slapped face”AppearanceDelirium tremens could best be described asPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A) Disorganized thinking, feelings of terror and non-purposeful behaviorB)A generalized shaking of the body accompanied by repetitive thoughtsC)An excited state accompanied by disorientation, hallucination and tachycardiaD) Single or multiple jerks caused by rapid contracting musclesThe correct answer is C: An excited state accompanied by disorientation, hallucination and tachycardiaAn ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?A) “Have you had a recent heart attack?”B)”Do you become short of breath during your normal dailyactivities?”C)”How many pillows do you use at night to sleep comfortably?”D) “Do you smoke?”PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is B: “Do you become short of breath during your normal daily activities?”The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk fordevelopment of which problem?A) Chronic vessel plaque formationB)Pulmonary embolismC)Occlusions at the vessel bifurcationsD) Coronary artery aneurysmsPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023The correct answer is D: Coronary artery aneurysmsThe nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which finding is most likely to occur?A) Chest painB)Peripheral edemaC)Nail clubbingD) LethargyThe correct answer is B: Peripheral edemaWhile working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior?A) Sexual promiscuityB)Poor body imagePHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023C)Dropping out of schoolD) Drug experimentationThe correct answer is B: Poor body imageThe nurse should initiate discharge planning for a clientA) When the client or family demonstrate readiness to learn self care modalitiesB)When informed that a date for discharge has been determinedC)Upon admission to the emergency roomD) When the client’s condition is stabilized on the assigned unitThe correct answer is C: Upon admission to the emergency roomThe nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client?PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023A) Protection for the granulation tissueB)Heal infectionC)Decried escharD) Keep the tissue intactThe correct answer is D: Keep the tissue intactPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023
PHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023When providing nursing measures to relieve a 102-degree Fahrenheit fever in a toddler with an infection, what is the most effective intervention?A) Use medications to lower the temperature set pointB)Apply extra layers of clothing to prevent shiveringC)Immerse the child in a tub containing cool waterD) Give a tepid sponge bath prior to giving an antipyreticThe correct answer is A: Use medications to lower the temperature set pointPHILOSOPHY 600 HESI PN EXIT V3 TEST BANK All 160 Questions & Answers!! New Update 2022-2023