PN HESI EXIT V1 & V2 LATEST 2022-2023 EXAM/ HESI PN V1 & V2 LATEST EXAM 221 REAL EXAM QUESTIONS AND CORRECT ANSWERS | VERIFIED ANSWERS AGRADE

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PN Hesi Exit V1

Question 1

A school-age client with diabetes isplaced on anintermediate-

acting insulin and regular insulin before breakfastand before

dinner. She will receive a snack of milkand cereal at bedtime.

What does the nurse tell the clientthe snack isintended to do?

You Selected:

Prevent late nighthypoglycemia.

Correct response:

Prevent late nighthypoglycemia.

Question2

A well-known public official of a small communityis admittedto

the emergency department following anepisode of chest pain.

Several nurses from the medical unit are aware ofthe admission and

access the official’s electronic medical record to obtain a status

update. What is the best response for the nurse manager tomake to

the nurses regarding this situation?

You Selected:

• “Assessing the official’s medical record is a breach of

confidentiality.”

Correct response:

• “Assessing the official’s medical record is a breach of

confidentiality.”

Question3

A four-year-old child is diagnosedashaving acute lymphocytic

leukemia. The white blood cell (WBC) count, especially the

neutrophil count,islow. What isthe most important intervention the

nurse should teach the parents?

You Selected:

• Protect your child from infections because his resistance to

infection is decreased

Correct response:

• Protect your child from infections because his resistance to

infection is decreased

Question 4

The nurse is caring for a client with influenza. The most effective

way to decrease the spread of microorganisms is:

You Selected:

• placing the client in isolation.

Correct response:

• washing the hands frequently.

Question 5

A client with a history ofhypertension has been prescribed a new

antihypertensive medication and is reporting dizziness. Which is

the best way for the nurse to assess blood pressure?

You Selected:

• in the supine, sitting, and standing positions

Correct response:

• in the supine, sitting, and standing positions

Question 6

A client has a soft wrist-safety device. Which assessment finding

should the nurse investigate further?

You Selected:

• cool, pale fingers

Correct response:

• cool, pale fingers

Question 7

A nurse is caring for a female client before surgery. The client states

that she isglad that she will not be going through menopause as a

result of her surgery and isonly having her uterus removed. The

nurse reviews the consent form and notes that the surgery isfor a

total abdominal hysterectomy witha salpingo-oophorectomy. What

should the nurse do in this situation?

You Selected:

• Contact the surgeon to explain that the client needs further

clarification regarding surgery.

Correct response:

• Contact the surgeon to explain that the client needs further

clarification regarding surgery.

Question 8

A young client diagnosed with schizophrenia istalking with the

nurse and says, “You know, when I thought everyone was out toget

me, I was stayingin my apartment all the time. Now, I would like to

get outand dothings again.” What isthe best initial response bythe

nurse?

You Selected:

• “What activities did you enjoy in the past?”

Correct response:

• “What activities did you enjoy in the past?”

Question 9

A client with anemia has been admitted tothe medical-surgical unit.

Which assessment findings are characteristic of iron deficiency

anemia?

You Selected:

• nausea, vomiting, and anorexia

Correct response:

• dyspnea, tachycardia, and pallor

Question 10

The nurse isdiscontinuing anintravenouscatheter ona 10-year-old

client with hemophilia. What would bethe most important

intervention for this client?

You Selected:

• Apply firm pressure on the site for 5 minutes after removal.

Correct response:

• Apply firm pressure on the site for 5 minutes after removal.

Question 11

When a client returns from the recovery room postmastectomy, an

initial postoperative assessment is performed by the nurse. What is

the nurse’s priority assessment?

You Selected:

• checking the dressing, drain, and amount of drainage

Correct response:

• assessing the vital signs and oxygen saturation levels

Question 12

A client with an uncomplicated term pregnancy arrives atthe labor-

and-delivery unit in early labor saying that she thinks her water has

broken. What is the nurse’sbest action?

You Selected:

• Ask what time this happened and note the color, amount, and

odor of the fluid.

Correct response:

• Ask what time this happened and note the color, amount, and

odor of the fluid.

Question 13

When documenting the care of a client, the nurse is aware of the

need to use abbreviations conscientiously and safely. This includes

You Selected:

• ensuring the abbreviations are understandable to clients who

may seek access to their health records

Correct response:

• limiting abbreviations to those approved for use by the

institution

Question 14

During routine prenatal screening, a nurse tells a client that her

blood sample willbeused for alpha fetoprotein (AFP) testing.

Which statement best describes what AFP testing indicates?

You Selected:

• “This screening indicates if your baby’s lungs are mature.”

Correct response:

• “This test will screen for spina bifida, Down syndrome, or

other genetic defects.” Document continues below

Discover more from:

Nursing fundamental (PN 200)(PN 200)

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Question 15

A client is recovering from an infected abdominal wound. Which

foods should the nurse encourage the client to eat tosupport wound

healing and recovery from the infection?

You Selected:

• chicken and orange slices

Correct response:

• chicken and orange slices

Question 16

A nurse suspects that the laboring client may have been physically

abused by her partner. What isthe most appropriate interventionby

the nurse?

You Selected:

• Collaborate with the interprofessional team to make a referral

to social services.

Correct response:

• Collaborate with the interprofessional team to make a referral

to social services.

Question 17

A client is newly diagnosed with asthma. While learning to use a

metered dose inhaler (MDI) for delivery of a short-term beta

agonist, the client asks if a spacer is appropriate to use with this

device. What is thenurse’s best response?

You Selected:

• “No, a spacer is not recommended because it can increase the

risk of developing oropharyngeal candidiasis.”

Correct response:

• “Yes, a spacer is recommended because it increases the

amount ofmedication that isdelivered tothe lungs.”

Question 18

The nurse is planning care for a client who had surgery for

abdominal aortic aneurysm repair 2 days ago. The pain medication

and the use of relaxation and imagery techniques are notrelieving

the client’s pain, and the client refuses to get out of bed to ambulate

as prescribed. The nurse contacts the health care provider (HCP),

explains the situation, and provides information about drug dose,

frequency ofadministration, the client’s vital signs, and the client’s

score on the pain scale. The nurse requests a prescription for a

different, orstronger, pain medication. The HCP tells the nurse that

the current prescription for pain medication is sufficient for this

client and that the client will feel better inseveral days. What should

the nurse do next?

You Selected:

• Explain to the HCP that the current pain medication and other

strategies are not helping the client andit is making it difficult

for the client to ambulate as prescribed.

Correct response:

• Explain to the HCP that the current pain medication and other

strategies are not helping the client andit is making it difficult

for the client to ambulate as prescribed.

Question 19

The nurse is making a room assignment for a client whose

laboratory test result indicate pancytopenia. Which client should the

nurse put into the same room with the client with pancytopenia?

You Selected:

• a client with digoxin toxicity

Correct response:

• a client with digoxin toxicity

Question 20

A community health nurse provides a client with information about

a local support group for those with multiple sclerosis. Providing

this informationisan example of which of the following?

You Selected:

• A referral.

Correct response:

• A referral.

Question 21

A nurse workingona neurologic floor has received reports onfour

clients. After identifying priority assessment data for eachclient,

which client should the nurse investigate first?

You Selected:

• the client admitted after a head injury in a motor vehicle who

reports nausea

Correct response:

• the client admitted after a head injury in a motor vehicle who

reports nausea

Question 22

The mother of anadolescent client who is diagnosed with

oppositional defiant disorder tells the nurse that she has read

extensively onthis disorder and does not believe the diagnosis is

correct for her daughter. Which response by the nurse is

appropriate?

You Selected:

• “Tell me what you’ve found in your reading that’s leading

you to that conclusion.”

Correct response:

• “Tell me what you’ve found in your reading that’s leading

you to that conclusion.”

Question 23

A nurse prepares a client’s medicationbyreconstituting a multi-dose

vial ofmedication. What other nursing interventions should the

nurse take? Select all that apply.

You Selected:

• Label the vial with the strength of the medication.

• Store the multi-dose vial in a secure place.

• Initial the vial as the person reconstituting the medication.

Correct response:

• Label the vial with the strength of the medication.

• Store the multi-dose vial in a secure place.

• Initial the vial as the person reconstituting the medication.

Question 24

Because of religious beliefs, a client, who is an Orthodox Jew,

refuses to eat hospital food. Hospital policy discourages food from

outside the hospital. The nurse should next:

You Selected:

• discuss the situation and possible courses of action with the

dietitian and the client.

Correct response:

• discuss the situation and possible courses of action with the

dietitian and the client.

Question 25

After a plaster cast has been appliedto the armof a child with a

fractured right humerus, the nurse completes discharge teaching.

The nurse should evaluate the teachingas successful when the

mother agrees toseek medical advice if the child experiences which

symptom?

You Selected:

• fussiness and reports that the cast is heavy

Correct response:

• inability to extend the fingers on the right hand

Question 26

While shopping, a nurse meets a neighbor who asks about a friend

receiving treatment at the nurse’s clinic. What is the

nurse’s most appropriateresponse?

You Selected:

• “I’m sorry, I can’t disclose client information.”

Correct response:

• “I’m sorry, I can’t disclose client information.”

Question 27

When assessingan 18-year-old primipara who gave birth under

epidural anesthesia 24 hours ago, the nurse determines that the

fundus is firm buttothe right of midline. Based on this finding, the

nurse should further assess for which complication?

You Selected:

• urinary retention

Correct response:

• urinary retention

Question 28

Which situation demonstrates correct principles ofconfidentiality?

You Selected:

• Two nurses alone in an elevator are discussing a client’s

status.

Correct response:

• An emergency department nurse reports suspected child

abuse.

Question 29

The nurse in a psychiatric unit has formed a therapeutic relationship

with a client with a borderline personality disorder. When the client

is readmitted to the unit for a suicide attempt, the nurse exclaims to

another staff nurse, “Why? Everything was going well. How could

they do this to me?” What response by the staff nurse reflects an

understanding of the client’s borderline disorder?

You Selected:

• “Clients with borderline disorder act out to relieve anxiety,

and something must have provoked a great deal of anxiety.”

Correct response:

• “Clients with borderline disorder act out to relieve anxiety,

and something must have provoked a great deal of anxiety.”

Question 30

A childisreceiving total parenteral nutrition(TPN). During TPN

therapy, the most important nursing action is:

You Selected:

• monitoring the blood glucose level closely.

Correct response:

• monitoring the blood glucose level closely.

Question 31

A 9-year-old client isbrought tothe emergency department with a

sutured wound with purulent drainage. The area around the wound

is red and warm to the touch, and the child is febrile. The parents

want to knowthe significance ofthe purulentdrainage. What is

the best response by the nurse?

You Selected:

• “The drainage is an indication that the sutures were not tight

enough.”

Correct response:

• “If a wound heals on the surface but infection remains, it will

open and drain.”

Question 32

A 19-year-old primigravid clientat 38 weeks’ gestation is 7 cm

dilated, and the presenting part is at +1 station. The client tells the

nurse, “I need to push!” What should the nurse do next?

You Selected:

• Instruct the client to use a pant-blow pattern of breathing.

Correct response:

• Instruct the client to use a pant-blow pattern of breathing.

Question 33

A client with cystic fibrosis develops pneumonia. To decrease the

viscosity of respiratory secretions, the physician orders

acetylcysteine. Before administering the first dose, the nurse checks

the client’s history for asthma. Acetylcysteine must be used

cautiously in a client with asthma becauseit

You Selected:

• may induce bronchospasm.

Correct response:

• may induce bronchospasm.

Question 34

Bone resorption is a possible complication of Cushing’sdisease. To

help the client prevent this complication, what should the nurse

recommend to the client?

You Selected:

• Maintain a regular program of weight-bearing exercise.

Correct response:

• Maintain a regular program of weight-bearing exercise.

Question 35

A client rates the pain level of a migraine an 8on a scale of 1-10.

How would the nurse administer the medication to give the client

the quickest relief?

You Selected:

• intravenous (IV)

Correct response:

• intravenous (IV)

Question 36

A client withParkinson’s disease who is scheduled for

physiotherapy isexperiencing nausea and weakness. What is

the mostappropriate actionby the nurse?

You Selected:

• Assess the nausea and weakness and call physiotherapy to

cancel or reschedule the appointment.

Correct response:

• Assess the nausea and weakness and call physiotherapy to

cancel or reschedule the appointment.

Question 37

Which intervention should the nurse include in the plan of care to

ensure adequate nutrition for a very active, talkative, and easily

distractible client who is unable to sit through meals?

You Selected:

• Offer the client nutritious finger foods.

Correct response:

• Offer the client nutritious finger foods.

Question 38

Which activity should the nurse recommend tothe client on an

inpatient unit when thoughts of suicide occur?

You Selected:

• playing a card game with other clients

Correct response:

• talking with the nurse

Question 39

A nurse is teaching a client with multiple sclerosis (MS). When

teaching the client how toreduce fatigue, the nurse should tell the

client to

You Selected:

• rest in an air-conditioned room.

Correct response:

• rest in an air-conditioned room.

Question 40

An apartment fire spreads to seven apartment units. Victims suffer

burns, minor injuries, and broken bones from jumping from

windows. Which client should be transportedfirst?

You Selected:

• a 10-year-old with a simple fracture of the humerus who is in

severe pain

Correct response:

• a middle-aged man with no injuries who has rapid respirations

and coughs

Question 41

A 26-year-old primigravida visiting the prenatal clinic for her

regular visitat 34 weeks’gestation tells the nurse that she takes

mineral oil for occasional constipation. What should the nurse

should instruct the client todo?

You Selected:

• Avoid mineral oil because it interferes with the absorption of

fat-soluble vitamins.

Correct response:

• Avoid mineral oil because it interferes with the absorption of

fat-soluble vitamins.

Question 42

A client is receiving chemotherapy that has the potential to cause

pulmonary toxicity. Which signs orsymptoms indicates a toxic

response to the chemotherapy?

You Selected:

• cough and shortness of breath

Correct response:

• cough and shortness of breath

Question 43

A nurse observes a physician providing care to aninfectious client

without the use of personal protective equipment. What should the

nurse do first?

You Selected:

• Notify the unit manager.

Correct response:

• Discuss the breach of practice with the physician.

Question 44

The nurse observes a client ina group whoisreminiscing about his

past. Which effect should the nurse expect reminiscingto have on

the client’s functioning in the hospital?

You Selected:

• Decrease the client’s feelings of isolation and loneliness.

Correct response:

• Decrease the client’s feelings of isolation and loneliness.

Question 45

A nurse, a licensed practical nurse (LPN), and a nursing assistant

are caring for a group ofclients. The nurse asks the nursing assistant

to check the pulse oximetry level of a client who underwent

laminectomy. The nursing assistant reports that the pulse oximetry

reading is89%. The client Kardex contains an order for oxygen

application at 2 L/min should the pulse oximetry level fall below

92%. The nurse is currently assessing a postoperative client who

just returned from the postanesthesia care unit. How should the

nurse proceed?

You Selected:

• Ask the LPN to obtain vital signs and administer oxygen at 2

L/min to the client who underwent laminectomy.

Correct response:

• Ask the LPN to obtain vital signs and administer oxygen at 2

L/min to the client who underwent laminectomy.

Question 46

A physician orders a stool culture to help diagnose a client with

prolonged diarrhea. The nurse who obtains the stool specimen

should

You Selected:

• collect the specimen in a sterile container.

Correct response:

• collect the specimen in a sterile container.

Question 47

A client returns tothe nursing division after a procedure. The client

tells the nurse that the client was awake during the procedure and

recalls certain events. What is the nurse’s priorityintervention?

You Selected:

• Ask for additional information from the client.

Correct response:

• Ask for additional information from the client.

Question 48

The nurse isobserving an unlicensed assistive personnel (UAP) give

care toa client after gynecologic surgery. The nurse should

intervene if the UAP:

You Selected:

• ambulates the client.

Correct response:

• massages the client’s legs.

Question 49

For a client with Graves’ disease, which nursing intervention

promotes comfort?

You Selected:

• maintaining room temperature in the low-normal range

Correct response:

• maintaining room temperature in the low-normal range

Question 50

A client is admittedto the hospital because of threatening,

aggressive behavior toward his family. In the first group meeting

after the client is admitted, another client sits near the nurse and

says loudly, “I’m sitting here because I’m afraidofTed. He’s sobig,

and I heard him talk about hitting people.” The nurse should say to

the client:

You Selected:

• “Everyone is here for different problems. You know you don’t

have to worry.”

Correct response:

• “It’s frightening to have new people on the unit. We’re here to

talk about things like being afraid.”

Question 51

A nurse ispreparingtoadminister anI.V. containing dextrose 10%

in ¼ normal saline solution to a 6-month-old infant. The nurse

should select which tubing tosafely administer the solution?

You Selected:

• I.V. tubing with a macrodrip chamber

Correct response:

• I.V. tubing with a volume-control chamber

Question 52

What is the priority nursing intervention in the postictal phase of a

seizure?

You Selected:

• Assess the client’s breathing pattern.

Correct response:

• Assess the client’s breathing pattern.

Question 53

The fire alarm sounds onthe maternal-neonatal unit at 0200. How

can a nurse best care for the unit’s clients during a fire alarm?

You Selected:

• Immediately evacuate the unit.

Correct response:

• Close all of the doors on the unit.

Question 54

The nurse issuctioning a client’stracheostomy. For whatreason

during the procedure does the nurse complete the above action?

You Selected:

• to lubricate the outside of the suction catheter

Correct response:

• to clear secretions from the tubing

Question 55

A primiparous client is on a regular diet 24hours postpartum. The

client’s mother asks the nurse if she can bring her daughter some

“special foods from home.” The nurse responds, based on the

understanding about which principle?

You Selected:

• The client’s health care provider (HCP) needs to give

permission for the foods.

Correct response:

• The mother can bring the daughter any foods that she desires.

Question 56

A parent brings a 5-year-old childtoa weekend vaccination clinic to

prepare for school entry. The nurse notes that the child has nothad

any vaccinations since 4 months of age. What isthe best way for the

nurse to determine how to catch-up the child’s vaccinations?

You Selected:

• Contact the child’s health care provider (HCP) during office

hours.

Correct response:

• Review nationally published immunization guidelines.

Question 57

A client isadmitted to the labor and delivery unitinlabor with

blood flowing down her legs. What would bethe priority nursing

intervention?

You Selected:

• Monitor fetal heart tones.

Correct response:

• Monitor fetal heart tones.

Question 58

A nurse administers incorrect medication toa client. After assessing

the client, and completing an incident report, which is

the priority actionbythe nurse?

You Selected:

• Complete an adverse drug reaction (ADR) report.

Correct response:

• Report the incident to risk management.

Question 59

A multipara at 16 weeks’ gestation isdiagnosed as having a fetus

with probable anencephaly. The client isfrom a conservative faith

and has decidedto continue the pregnancy and donate the neonatal

organs after the death ofthe neonate. What should the nurse do?

You Selected:

• Explore his or her own feelings about the issues of

anencephaly and organ donation.

Correct response:

• Explore his or her own feelings about the issues of

anencephaly and organ donation.

Question 60

A client who is tohave a vaginal radium implant tells the nurse she

is concerned about being radioactive. The nurse should tell the

client:

You Selected:

• “The radiation is necessary to treat your tumor.”

Correct response:

• ”The radioactive material is controlled and stays with the

source; once the material is removed, no radioactivity will

remain.”

Question 61

An agitated, confused client arrives in the emergency department.

The client’s history includes type 1 diabetes, hypertension, and

angina pectoris. Assessment reveals pallor, diaphoresis, headache,

and intense hunger. A stat blood glucose sample measures42mg/dl,

(2.3 mmol/L) and the client is treated for anacute hypoglycemic

reaction. After recovery, the nurse teaches the clientto treat

hypoglycemia by ingesting

You Selected:

• 18 to 20 g of a simple carbohydrate.

Correct response:

• 15 g of a simple carbohydrate.

Question 62

A competent clientina long-term care facility refuses totake oral

diuretic medication. The nurse informs the client that if the

medication isn’ttaken, restraints will beapplied, and the medication

will be given by injection. Which legal tort best describes this

nurse’s statement?

You Selected:

• negligence

Correct response:

• assault

Question 63

A client with weakness and tingling in both legs is admitted tothe

medical-surgical unit with a tentative diagnosis of Guillain-Barré

syndrome. Onadmission, which assessment is most important for

this client?

You Selected:

• lung auscultation and measurement of vital capacity and tidal

volume

Correct response:

• lung auscultation and measurement of vital capacity and tidal

volume

Question 64

Which client should the nurse assess first?

You Selected:

• a client with chronic hypertension whose blood pressure today

is 182/98 mm Hg

Correct response:

• a client being treated for chronic stable angina who reports a

recent increase in chest pain frequency

Question 65

A nurse iscaring for a client during the first postpartum day. The

client asks the nurse how torelieve pain from her episiotomy. What

should the nurse instruct the woman todo?

You Selected:

• Take a sitz bath.

Correct response:

• Apply an ice pack to her perineum.

Question 66

The nurse is admitting a hospital client who does notspeak English

and who is accompanied bythe client’s school-aged child. The client

appears to be in pain, but the nurse isunable to assess the character

or history of the client’s pain. How should the

nurse best communicate with the client?

You Selected:

• Have a hospital interpreter come to the assessment; defer the

assessment if none is available.

Correct response:

• Enlist the help of a hospital interpreter; ask the son to

translate if none is readily available.

Question 67

A client who has just been diagnosed with mixed muscular

dystrophy asks the nurse about the usual course ofthis disease. How

should the nurse respond?

You Selected:

• “You should ask your physician about that.”

Correct response:

• “You may experience progressive deterioration in all

voluntary muscles.”

Question 68

The nurse is caring for a client with type 2 diabetes who has been

admitted with hyperglycemia. What is the most important

consideration when developing a teaching plan for this client?

You Selected:

• Assess what the client already knows, then identify learning

needs.

Correct response:

• Assess what the client already knows, then identify learning

needs.

Question 69

A nurse isteaching a pregnant client how todistinguish false labor

contractions from true labor contractions. Which statement by the

client indicates an understandingof this concept?

You Selected:

• “False labor contractions start in the back and radiate to the

abdomen.”

Correct response:

• “False labor contractions are usually felt in the abdomen.”

Question 70

A client has been taking fluoxetine, 40 mg dailyat 0900 for 1 week.

The client states he feels nervous and has had diarrhea. What

interpretation does the nurse make about the client’s symptoms?

You Selected:

• important, probably suggesting a decrease in dosage or

change to another medication

Correct response:

• important, probably suggesting a decrease in dosage or

change to another medication

Question 71

Which instruction should a nurse give toa client with diabetes

mellitus when teaching about “sick day rules”?

You Selected:

• “Test your blood glucose every 4 hours.”

Correct response:

• “Test your blood glucose every 4 hours.”

Question 72

In which maternal locations would the nurse place the ultrasound

transducer of the external electronic fetal heart rate monitor if a

fetus at 34weeks’ gestation is in the left occipitoanterior (LOA)

position?

You Selected:

• near the symphysis pubis

Correct response:

• below the umbilicus on the left side

Question 73

The client with a cervical spinal cord injuryis admitted tothe

rehabilitation unit with skeletal traction(Gardner-Wells Traction).

What nursing actions are a priority when caring for the client?

Select all that apply.

You Selected:

• Assess the client’s skin integrity.

• Maintain active range of motion.

• Maintain proper body alignment.

Correct response:

• Assess the client’s skin integrity.

• Maintain proper body alignment.

• Assess client’s neurological function.

Question 74

An older client with diabetes who has been maintained on

metformin has been scheduled for a cardiac catheterization. The

nurse should verify that the health care provider (HCP) has written

which prescription for takingthe metforminbefore the procedure?

You Selected:

• Withhold the metformin.

Correct response:

• Withhold the metformin.

Question 75

A client tells the nurse that she doesn’t have funds to buy

diapers and formula. The nurse should refer this client to a

You Selected:

social worker.

Correct response:

social worker.

Question 76

A voluntary client inafacilitydecides toleave the unit before

treatment is complete. To detain the client, the nurse refuses

to return the client’s personal effects. This action is an

example of:

You Selected:

slander.

Correct response:

false imprisonment.

Question 77

A postpartum multiparous client diagnosed with endometritis

is to receive intravenous antibiotic therapy with ampicillin.

Before administeringthis drug, the nurse must take which

action?

You Selected:

Ask the client ifshe has any drug allergies.

Correct response:

Ask the client ifshe has any drug allergies.

Question 78

A 2-year-old is being seen in the outpatient department for a

minor injury. The nurse places the child on the examining

table, and the child begins to scream and cry. No attempts to

comfort the toddler are effective. Which is the nurse’s best

action?

You Selected:

Allow the parents to hold the child in their lap for the

assessment.

Correct response:

Allow the parents to hold the child in their lap for the

assessment.

Question 79

The nurse is teaching an adolescent how to self-administer

insulin. Whichof the following is a priority for the nurse to

emphasize about insulin administration?

You Selected:

Insulin injections are administered in subcutaneous

tissue.

Correct response:

Insulin injections are administered in subcutaneous

tissue.

Question 80

A 2 1/2-year-old child and his 2-month-old sibling are

brought to the clinic by their father, who explains that the

older child says “no” whenever asked to do something. The

nurse should explain that the negativism demonstrated by

toddlers is frequently an expression of which characteristic?

You Selected:

pursuit of autonomy

Correct response:

pursuit of autonomy

Question 81

A client with burns is to have a whirlpool bath and dressing

change. What should the nurse do 30minutes before the

bath?

You Selected:

Administer an analgesic.

Correct response:

Administer an analgesic.

Question 82

The team leader has noticed a sharp increase in medication

errors associated with IV antibiotic administration over the

last 2 months. The group that could offer resources for

tracking medication errors and improving care outcomes is

the:

You Selected:

Pharmacy and Products Office.

Correct response:

Quality Improvement and Risk Management

Department.

Question 83

A physician orders digoxin elixir for a client with heart failure.

Immediately before administering this drug, the nurse must

check the client’s

You Selected:

apical pulse.

Correct response:

apical pulse.

Question 84

One ofthe myths about sexual abuse ofyoung children is

that it usually involves physically violent acts. Which behavior

is more likely to be used by the abusers?

You Selected:

tying the child down

Correct response:

coercion as a result of the trusting relationship

Question 85

While takingan admission history, a client tells a nurse that

they were a former IV drug abuser. Which test would

be most important for this client to undergo?

You Selected:

hepatitis C virus test

Correct response:

hepatitis C virus test

Question 86

A 44-year-old client has been experiencing spotting, nausea,

vomiting, and fatigue. A positive pregnancy test and an

ultrasound confirm a 13 week gestation. The client had three

prior miscarriages with no term births. What does the nurse

recognize as the greatest risk factor for the client at this

time?

You Selected:

pregnancy loss

Correct response:

pregnancy loss

Question 87

The nurse isconducting a routine risk assessment at a

prenatal visit. Which question would be the best to screen

for intimate partner violence?

You Selected:

“How safe do you feel in your home?”

Correct response:

“How safe do you feel in your home?”

Question 88

A child being treated for conduct disorder is the last person

on the unit selected for an activity. The nurse should expect

the client to demonstrate:

You Selected:

withdrawal.

Correct response:

aggression.

Question 89

A client who isparalyzed after a spinal cord injury needs to

be transferred to a stretcher. Which assistive device should

the nurse use to facilitate this transfer?

You Selected:

transfer board

Correct response:

transfer board

Question 90

A client with diabetes is taking insulin lispro injections. At

what timeshould the nurse advise the client to eat?

You Selected:

within 10 to 15minutes after the injection.

Correct response:

within 10 to 15minutes after the injection.

Question 91

Which ofthe following clients should the nurse assess first?

You Selected:

the client who is a child with stridor and nasal flaring

Correct response:

the client who is a child with stridor and nasal flaring

Question 92

Which mediation can the nurse administer through a

nasogastric(NG) tube?

You Selected:

acetaminophen

Correct response:

acetaminophen

Question 93

A client has been prescribed corticosteroids. The nurse

would also anticipate an order for

You Selected:

blood glucosechecksevery6hours.

Correct response:

blood glucosechecksevery6hours.

Question 94

When preparing for a spiritual counselor to visit a

hospitalized client, the nurse should

You Selected:

take measures to ensure privacy during the counselor’s

visit.

Correct response:

take measures to ensure privacy during the counselor’s

visit.

Question 95

A client with pernicious anemia asks why she must take

vitamin B12 injections forever. Whichis the

nurse’s

best

response?

You Selected:

“The reason for your vitamin deficiency is an increased

requirement for the vitamin because of rapid red blood

cell production.”

Correct response:

“The reason for your vitamin deficiency is an inability to

absorb the vitamin because the stomach is not

producing sufficient amounts of a factor that allows the

vitamin tobe absorbed.”

Question 96

A client is admitted to the emergency department with a

ruptured abdominal aortic aneurysm. No family members are

present, and the surgeon instructs the nurse to take the client

to the operating room immediately. Which action should the

nurse take regarding informed consent?

You Selected:

Take the client to the operating room for surgery

without informed consent.

Correct response:

Take the client to the operating room for surgery

without informed consent.

Question 97

A nurse comingonto the night shift assesses aclientwho

gave birth vaginally that morning. The nurse finds that the

client’s vaginal bleeding has saturated two perineal pads

within 30minutes. What is the first action the nurse should

take?

You Selected:

Assessthe fundus and massage it if it’s boggy.

Correct response:

Assessthe fundus and massage it if it’s boggy.

Question 98

The nurse is caring for a client recently diagnosed with

hepatitis C. Inreviewing the client’shistory, what information

will be most helpful as the nurse develops a teaching plan?

The client:

You Selected:

traveled to Central America recently and ate uncooked

vegetables.

Correct response:

has a known history of sexually transmitted disease.

Question 99

A child with meningococcal meningitis is being admitted to

the pediatric unit. In preparation for the child’s arrival, what

shouldthe nurse do

first

?

You Selected:

Institute droplet precautions.

Correct response:

Institute droplet precautions.

Question 100

The selectionofa nursing care delivery system (NCDS) is

critical to the success of client care in a nursing area. Which

factoris essential to the evaluation of an NCDS?

You Selected:

identifying who will be responsible for making client

care decisions

Correct response:

identifying who will be responsible for making client

care decisions

Question 101

Which of the following observations by the nurse would

indicate that a client isunable totolerate a continuation ofa

tube feeding?

You Selected:

formula in the client’s mouth during the feeding, and

increased cough

Correct response:

formula in the client’s mouth during the feeding, and

increased cough

Question 102

A client undergoes a biopsy ofa suspicious lesion. The

biopsy report classifies the lesion according tothe TNM

staging system asfollows: TIS, N0, M0. What does this

classification mean?

You Selected:

no evidence of primary tumor, no abnormal regional

lymph nodes, and noevidence ofdistant metastasis

Correct response:

carcinoma in situ, no abnormal regional lymph nodes,

and noevidence of distant metastasis

Question 103

A physician has ordered a heating pad for an elderly client’s

lower back pain. Which item would be most important for a

nurse to assess before applying the heating pad?

You Selected:

Client’s levelof consciousness

Correct response:

Client’s levelof consciousness

Question 104

Which nifedipine-related side effect should the nurse

be most concerned with when caring for a new stroke

admission?

You Selected:

hypotension

Correct response:

hypotension

Question 105

A client at 27 weeks gestation experiences uterine cramping

and also secretes a small amount of bright red bleeding and

mucus. The client calls her prenatal clinic nurse. Whichof the

following recommendations is most appropriate from the

nurse?

You Selected:

Instruct the client to go to an emergency room for an

urgent assessment.

Correct response:

Instruct the client to go to an emergency room for an

urgent assessment.

Question 106

A 16-year-old primiparous client has decided to place her

baby for adoption. The adoptive parents are on their way to

the hospital when the mother says, “I want to see the baby

one last time.” What should the nurse do?

You Selected:

Allow the client to see and hold the baby for as long as

she desires.

Correct response:

Allow the client to see and hold the baby for as long as

she desires.

Question 107

A 37-week gestation client is on bed rest for gestational

hypertension. The nursing student and nurse are visiting the

client in her home and need to perform external fetal

monitoring (EFM). The student nurse asks the nurse if the

student nurse is allowed to perform this skill. What is the

nurse’s most appropriate response?

You Selected:

“Yes, but only after you read about the procedure in the

regional policy and procedure manual.”

Correct response:

“Yes, but I will demonstrate it once and then supervise

you while you perform the procedure.”

Question 108

Parents tell a nurse that they have not met their goalof home

management of their child with schizoaffective disorder. They

report that the client poses a threat to their safety. Based on

this information, what recommendation should the nurse

make?

You Selected:

Evaluate the client for voluntary admission to a mental

health facility.

Correct response:

Evaluate the client for voluntary admission to a mental

health facility.

Question 109

A client has been diagnosed with metabolic alkalosis. The

nurse should anticipate what finding from the client’s arterial

blood gases?

You Selected:

serum bicarbonate of 28 mEq/L

Correct response:

serum bicarbonate of 28 mEq/L

Question 110

A client on the adolescent psychiatric unit was admitted with

a diagnosis ofbody dysmorphic disorder. The clienthas not

been able to attend school or their part-time work over the

past year as a result of certain body obsessions. Recently,

the client shaved the hair all over their body, claiming, “It is

all growing weird.” What component of therapy would

be most important for the nurse to apply to this client?

You Selected:

The client is at high risk for suicide.

Correct response:

The client’s body image is real to the client.

Question 111

A client comes to the emergency department complaining of

chest pain. An electrocardiogram (ECG) reveals myocardial

ischemia and an anterior-wall myocardial infarction (MI).

WhichECG characteristicdoes the nurse expect to see?

You Selected:

prolonged PR interval

Correct response:

elevated STsegment

Question 112

A nurse notices that a large number of clients who receive

oxytocin to induce labor vomit as the infusion is started. The

nurse assesses the situation further and discovers thatthese

clients received no instruction before arriving on the unit and

haven’t fasted for 8 hours before induction. How should the

nurse intervene?

You Selected:

Initiate a unit policy involving staff nurses, certified

nurse-midwives, and physicians in teaching clients

before labor induction.

Correct response:

Initiate a unit policy involving staff nurses, certified

nurse-midwives, and physicians in teaching clients

before labor induction.

Question 113

A client comes to the clinic for evaluation. The client tells the

nurse, “Ihave been having headaches and dizziness. I looked

it up on the Internet, and I think I might have a brain tumor.”

The client hands the nurse a printout of what the client found.

Which response bythe nurse would be mostappropriate?

You Selected:

“Tell me more about where you found this information

that you gave me.”

Correct response:

“Tell me more about where you found this information

that you gave me.”

Question 114

During a home visit on the fourth postpartum day, a

primiparous client tells the nurse that she has been

experiencing breast engorgement. To relieve engorgement,

the nurse teachesthe client to use which intervention before

nursing her baby?

You Selected:

Apply anice cube to the nipples.

Correct response:

Express a small amount of breast milk.

Question 115

The nurse instructs the client on health maintenance

activities to help control symptoms from a hiatal hernia.

Which statement would indicate that the client has

understood the instructions?

You Selected:

“I will avoid lying down after a meal.”

Correct response:

“I will avoid lying down after a meal.”

Question 116

The parent asks the nurse about a 9-year-old child’s

apparent need for between-meal snacks, especially after

school. What information should the nurse include in the

teaching plan?

You Selected:

The child should eat the snacks the mother thinks are

appropriate.

Correct response:

The child should help with preparing the snacks.

Question 117

A client with rheumatoid arthritis tells the nurse, “Iknow it’s

important to exercise my joints so that I won’t lose mobility,

but my joints are so stiff and painful that exercising is

difficult.” Which response by the nurse would

be most appropriate?

You Selected:

“Stiffness and pain are part of the disease. Learn to

cope by focusing on activities you enjoy.”

Correct response:

“Take a warm tub bath or shower before exercising.

This may help with your discomfort.”

Question 118

The nurse assesses a child after heart surgery to correct

tetralogy of Fallot. Which finding would the nurse report to

the healthcare provider as an indication that the client has

low cardiac output?

You Selected:

altered level ofconsciousness and thready pulse

Correct response:

altered level ofconsciousness and thready pulse

Question 119

A client who is positive for human immunodeficiency virus

(HIV) tells the nurse thatthe client’s significant other is the

only family member who knows the client’s health status.

What should the nurse do to keep the client’s health status

confidential? Select all that apply.

You Selected:

Ask all family members, except the client’s significant

other, to wait outside when she’s educating the client.

Use the hospital code for HIV when documentingcare.

Correct response:

Use the hospital code for HIV when documentingcare.

Ask all familymembers, except the client’s significant

other, to wait outside when she’s educating the client.

Question 120

What should the nurse do when the client with a diagnosis of

schizophrenia walks into group naked?

You Selected:

Lead the client to his room and help him dress if he

needs assistance.

Correct response:

Lead the client to his room and help him dress if he

needs assistance.

Question 121

Oxygen at the rate of 2 liters per minute through nasal

cannula is prescribed for a client with chronic obstructive

pulmonary disease (COPD). Which of the following

statements best describes why the oxygen therapyis

maintained at a relatively low concentration?

You Selected:

The cells in the alveoli are so damaged by the client’s

long history of respiratory problems that increased

oxygen levels and reduced carbon dioxide levels likely

will cause the cells to burst.

Correct response:

The client’s respiratory center is so used to high carbon

dioxide and low oxygen levels that changing these

levels mayeliminate hisstimulus for breathing.

Question 122

A client begins clozapine therapy after several other

antipsychotic agents failtorelieve psychotic symptoms. The

nurse instructs the client toreturn for weekly white blood cell

(WBC) counts toassess for which adverse reaction?

You Selected:

infection

Correct response:

granulocytopenia

Question 123

A client states, “Ihave abdominal pain.” Which assessment

question would best determine the client’s need for pain

medication?

You Selected:

“What does the pain feel like?”

Correct response:

“What does the pain feel like?”

Question 124

When developing the preoperative teaching plan for a 14-

month-old child with an undescended testis who is

scheduled tohave surgery, which method

is most appropriate?

You Selected:

Explain to the parents how the defect will be corrected.

Correct response:

Explain to the parents how the defect will be corrected.

Question 125

The nurse plans toplace graduated compression stockings

on a client in the preoperative setting. List in order the steps

the nurse will follow. All options must be used.

You Selected:

Review medical record and medical orders for

graduated compression stockings.

Identify the client and explain procedure.

Place the client in supine position.

Apply powder orlotion tolegs.

Smoothly pull the stocking overthe ankle and calf.

Turn the stocking inside out and ease the stocking over

the foot and heel.

Correct response:

Review medical record and medical orders for

graduated compression stockings.

Identify the client and explain procedure.

Place the client in supine position.

Apply powder orlotion tolegs.

Turn the stocking inside out and ease the stocking over

the foot and heel.

Smoothly pull the stocking overthe ankle and calf.

Question 126

A client with depression states, “I’m still feeling nauseous

after I take venlafaxine. Maybe I need something else.” What

should the nurse should tell the client todo?

You Selected:

Take venlafaxine only in the morning.

Correct response:

Take the medication atmealtime.

Question 127

Which information should the nurse include in the teaching

plan for a primiparous client who asks about weaning her

neonate?

You Selected:

“Eliminate the baby’s favorite feeding times first.”

Correct response:

“Gradually eliminate one feeding at a time.”

Question 128

A grandson calls the crisis center expressing concern about

his grandmother, who lost her husband a month ago. He

states, “She’s been in bed for a week and is not eating or

showering. She told me that she didn’t want to kill herself,

but it’s not like her to do nothing for herself. She won’t even

talk to me when I visit her.” The nurse encourages the

grandson to bring his grandmother to the center for

evaluation based on which reason?

You Selected:

The behaviors may reflect passive suicidal thoughts.

Correct response:

The behaviors may reflect passive suicidal thoughts.

Question 129

When caring for a client receiving haloperidol, the nurse

should assess for which problem?

You Selected:

extrapyramidal symptoms

Correct response:

extrapyramidal symptoms

Question 130

A nurse is administering daunorubicin through a peripheral

I.V.

line whenthe client complainsof burning at the insertion

site. The nurse notes no blood return from the catheter and

redness at the I.V. site. The client is most likely experiencing

which complication?

You Selected:

thrombosis

Correct response:

extravasation

Question 131

Which nursing intervention is essential in caring for a client

with compartment syndrome?

You Selected:

wrapping the affected extremity with a compression

dressing tohelp decrease the swelling

Correct response:

removing all external sources of pressure, such as

clothing and jewelry

Question 132

A primigravid client visits the clinicfor a routine examination

at 35 weeks’ gestation. The client’s blood pressure is near

the baseline of 120/74 mm Hg with no proteinuria or

evidence of facial edema. The client asks the nurse, “What

should I take if I get an occasional headache after looking at

my computer at work all day?” Which over-the-counter

medicine does the nurse consider to be safest for occasional

use bya pregnant client with no known risks?

You Selected:

acetaminophen

Correct response:

acetaminophen

Question 133

A depressed client in the psychiatric unit hasn’t been getting

adequate rest and sleep. To encourage restful sleep at night,

the nurse should:

You Selected:

encourage environmental stimulation during the

evening.

Correct response:

gently but firmly set limits on how much time the client

spends in bed during the day.

Question 134

A client has several patches of vesicles over both arms.

Which care should the nurse provide tothis client?

You Selected:

Instruct on the application of an antiparasitic agent.

Correct response:

Cover the draining areas with sterile gauze.

Question 135

A client is frustrated and embarrassed by urinary

incontinence. Which measure should the nurse include in a

bladder retraining program?

You Selected:

assessing present voiding patterns

Correct response:

assessing present voiding patterns

Question 136

A client with a cerebellar brain tumor is admitted to an acute

care facility. The nurse formulates a nursing diagnosis of Risk

for injury. Which “related-to” phrase should the nurse add to

complete the nursing diagnosis statement?

You Selected:

Related tovisual field deficits

Correct response:

Related toimpaired balance

Question 137

A nurse suspects that a child, age 4, is being neglected.

Which question should the nurse ask the parents tobest

assess the child’s nutritional status?

You Selected:

“What did your child eat for breakfast?”

Correct response:

“What did your child eat for breakfast?”

Question 138

A medication nurse is preparing to administer 0900

medications to a client with liver cancer. Which consideration

is the nurse’s highest priority?

You Selected:

purpose of the medication

Correct response:

metabolism of the medication

Question 139

After an intravenous pyelogram (IVP), the nurse should

include which measure in the client’s plan of care?

You Selected:

Encourage adequate fluid intake.

Correct response:

Encourage adequate fluid intake.

Question 140

The nurse receives the preoperative blood work report for a

client who is scheduled toundergo surgery. Which laboratory

finding should the nurse report to the surgeon and

anesthesiologist?

You Selected:

blood urea nitrogen, 15 mg/dL (5.4 mmol/L)

Correct response:

creatinine, 2.6 mg/dL (230 µmol/L)

Question 141

For the child experiencingexcessive vomiting secondary to

pyloric stenosis, the nurse should assess the child for which

acid-base imbalance?

You Selected:

metabolic alkalosis

Correct response:

metabolic alkalosis

Question 142

Which indicator is the best for determining whether a client

with Addison’s disease isreceiving the correct amount of

glucocorticoid replacement?

You Selected:

daily weight

Correct response:

daily weight

Question 143

The client withrecurring depression will be discharged from

the psychiatric unit. Which suggestion to the family

is most important to include in the plan of care?

You Selected:

Provide for a schedule of activities outside the home.

Correct response:

Involve the client inusual at-home activities.

Question 144

During the initial assessment, the nurse notes that the

neonate’s hands and feet appear blue while the neonate’s

torso appears pale pink. Whatshould the nurse do next?

You Selected:

Keep the neonate in an isolation incubator for at least 2

hours.

Correct response:

Place the infant skin to skin with the mother.

Question 145

Which findingis normal for a client during the icteric phase of

hepatitis A?

You Selected:

yellowed sclera

Correct response:

yellowed sclera

Question 146

A nurse is working on a surgical floor. The nurse must logroll

a client following a

You Selected:

cystectomy.

Correct response:

laminectomy.

Question 147

After receiving a report, the nurse is making out assignments.

Which client would be appropriate to assign to unlicensed

assistive personnel?

You Selected:

an 8-month-old with pneumonia who will be discharged

today

Correct response:

an 8-month-old with pneumonia who will be discharged

today

Question 148

A client, with heart failure, isreceivingfurosemide,40 mgIV.

The provider orders 40 mEq ofpotassium chloride in100 ml

of dextrose

5%

in water, to infuse over four hours. The

client’s most recent serum potassium level is 3.0 mEq/L. At

which infusion rate should the nurse set the IV pump?

Record your answer using a whole number.

Your Response:

67

Correct response:

25

Question 149

A client has expressed her desire to give birth with minimal

intervention. She is now moving into the active phase of

labor. What intervention by the nurse would be the priority of

care?

You Selected:

watchingfor rupture of the membranes

Correct response:

offering support by reviewing the short-pant form of

breathing

Question 150

A 35-year-old client who is 28weeks pregnant isadmitted for

testing. After reading the nursing notes, which

rationale best explains why a pregnant client would lie on her left

side when resting or sleepinginthe later stages of pregnancy?

You Selected:

• to prevent compression of the vena cava

Correct response:

• to prevent compression of the vena cava

Question 151

The laboratory comes todraw anHgb AIc. The client asks the nurse

what this test represents. Which statement would be correct?

You Selected:

• “This test reflects the average blood glucose over a period of

approximately 2-3 months.”

Correct response:

• “This test reflects the average blood glucose over a period of

approximately 2-3 months.”

Question 152

A client who recently had a stroke requires a cane to ambulate.

When teaching about cane use, the nurse should explain that the

reason for holding a cane onthe uninvolved side is to

You Selected:

• distribute weight away from the involved side.

Correct response:

• distribute weight away from the involved side.

Question 153

A 7-year-old has had anappendectomy on November 12. He has

had pain for the last 24hours. There isa prescription toadminister

acetaminophen with codeine every 3 to 4 hours asneeded. The

nurse is beginning the shift, and the child isrequesting pain

medication. The nurse reviews the chart below for pain history.

Based onthe information inthe medical record, what should the

nurse do next?

You Selected:

• Instruct the child to take deep breaths and blow his pain away.

Correct response:

• Administer the acetaminophen with codeine.

Question 154

A nurse is conducting aneducational program about advanced

directives for a group of adults at a local community center. The

nurse explains what the directives entail and how they are used.

After explaining this topic, the nurse determines that the teaching

was successful based onwhich statement bythe group?

You Selected:

• “The document allows us to choose what we want to have

happen.”

Correct response:

• “The document allows us to choose what we want to have

happen.”

Question 155

A nurse is caring for a full-term pregnant client in active labor. The

electronic fetal monitor reveals afetalheart rate (FHR)of less than

70 beats for 1 minute. What is the nurse’s priority intervention?

You Selected:

• Place the client on her left side and apply oxygen.

Correct response:

• Place the client on her left side and apply oxygen.

Question 156

The nurse is assessing a client with thigh high antiembolism

stockings. Assessment findings include redness, swelling, and pain

in the left calf. What is the priority action by the nurse?

You Selected:

• Notify the healthcare provider.

Correct response:

• Notify the healthcare provider.

Question 157

Which client statement indicates anunderstanding of the risk of

alcohol relapse?

You Selected:

• “I know I can stay dry if my wife keeps alcohol out of the

house.”

Correct response:

• “Stopping support groups and not expressing feelings can lead

to relapse.”

Question 158

A nurse iscaring for a client who has end-stage chronic obstructive

pulmonary disease receiving I.V. push morphine for pain

management. Duringrounds, the nurse discusses with the physician

the need to start the client ona continuous morphine infusion. The

nurse bases this request on the fact that:

You Selected:

• serving as a client advocate is an important role.

Correct response:

• serving as a client advocate is an important role.

Question 159

A client with posttraumatic stress disorder states, “You don’tknow

what I’ve been through. What can you do?”The nurse should

respond:

You Selected:

• “I haven’t been through what you have, but I’ll be better able

to understandif you tell me more about it.”

Correct response:

• “I haven’t been through what you have, but I’ll be better able

to understandif you tell me more about it.”

Question 160

A client was hospitalized for 1 week with major depression with

suicidal ideation. He istaking venlafaxine 75 mgthree times a day

and is planning to return to work. The nurse asks the clientif he is

experiencing thoughts ofself-harm. The client responds, “Ihardly

think about itanymore and wouldn’t doanything tohurt myself.”

The nurse should make which judgment about the client?

You Selected:

• The depression is improving, and the suicidal ideation is

lessening.

Correct response:

• The depression is improving, and the suicidal ideation is

lessening.

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