HESI MED SURG EXAM REVIEW UPDATED 2022 (Q&A) ADDED POSSIBLE QUESTIONS

HESI MED SURG EXAM REVIEW UPDATED 2022 (Q&A) ADDED POSSIBLE QUESTIONS

Hesi Med Surg review 2020/2021

1. What instruction should the nurse include in the discharge teaching

plan of a client who had a cataract extraction today?

a. Sexual activities may be resumed upon return home

b. Light housekeeping is permitted but avoid heavy lifting

c. Use a metal eye shield on operative eye during the day

d. Administer eye ointment before applying eye drops

2. A male adult comes to the urgent care clinic 5 days after being

diagnose with influenza. He is short of breath, febrile, and coughing

green colored sputum. Which intervention should the nurse implement

first?

a. Obtain a sputum sample for culture

b. Check his oxygen saturation level

c. Administer an oral antipyretic

d. Auscultate bilateral lung sound

3. An elder male client tells the nurse that he is loosing sleep because he

has to get up several times at night to go to the bathroom that he has

trouble starting his urinary stream and that he does not feel like his

bladder is ever completely empty. Which intervention should the nurse

implement?

a. collect a urine specimen for culture analysis

b. obtain a fingerstick blood glucose level

c. palpate the bladder above the symphysis pubis

d. review the client fluid intake

4. An adult client is admitted with diabetic ketoacidosis (DKA) and a

urinary tract infection (UTI) Prescriptions for intravenous antibiotics

and insulin infusion are initiated. Which serum laboratory value

warrants the most immediate intervention by the nurse?

a. blood ph of 7.30

b. glucose of 350 mg /dl

c. white blood cell count of 15000mm

d. potassium of 2.5 meq/l

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5. A client with sickle cell anemia develops a fever during the last hour of

administration of a unit of packed red blood cell. When notifying the

healthcare provider what information should the nurse provide first

using the SBAR communication process?

a. explain specific reason for urgent notification

b. preface the report by stating the clients name and admitting

diagnosis

c. communicate the pre-transfusion temperatures

d. optain prn prescription for acetaminophen for fever 101f

6. An adult male client is admitted for pneumocystis carinil pneumonia

(PCP) secondary to aids. While hospitalize he receives IV pentamidine

isethionate therapy. In preparing this client for discharge what

important aspect regarding his medication therapy should the nurse

explain?

a. AZT therapy must be stopped when IV aerosol pentamine is

being used.

b. IV

pentamine will be given until oral pentamine can be tolerated c.

d. Iv pentamine may offer protection to others aids related conditions

such as kaposis sarcoma

7. A client subjective data includes dysuria, urgency, and urinary

frequency.

What action should the nurse implement next?

a. collect a clean catch specimen

b. palpate the suprapubic region

c. instruct to wipe from front to back

d. inquire about recent sexual activity

8. A client tells the nurse that her biopsy results indicate that the cancer

cells are well differentiated How should the nurse respond?

a. offer the client reassurance that this information indicates that

the clients cancer cells are benign

b. explain that these tissue cells often respond more effectively to

radiation than to chemotherapy

c.

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It will be necessary to continue prophylactic doses of IV or

aerosol pentamine every month

ask the client in the healthcare provider has giving her any

information about the classification of her cancer

d. help the client make plans to begin inmediate treatment since her

cancer is likely to spread quickly

9. A client with a chronic kidney disease is treated on hemodialysis.

During the 1 treatment clients blood pressure drops from 150/90 to

80/30 Which action should the nurse take first?

a. monitor bp q45 minutes

b. lower the head of the chair and elevate feet

c. stop dialysis treatment

d. administer 5%albumin IV

10.A client with deep vain thrombosis (DVT) is receiving a continues

infusion of heparin sodium 25,000 unit in 5?xtrose injection 250ml.

The prescription indicates the dosage should be increase 900 units/hr.

The nurse should program the infusion pump to deliver how many

ml/hr?

=9

11.The nurse is obtaining the admission history for a client with

suspected peptic ulcer disease (PUD). Which subjective data reported

by the client supports this diagnosis?

a. upper mid abdominal gnawing and burning pain

b. severe abdominal cramps and diarrhea after eating spicy foods

c. marked loss of weight and appetite over the last few months

d. use of chewable and liquid antacids for indigestion

12.The nurse is providing preoperative education for a jewish client

schedule to receive a xenograft graft to promote burn healing. Which

information should the nurse provide this client?

a. the xenograft is taken from nonhuman sources

b. grafting increases the risk for bacterial infection

c. as the burn heals the graft permanently attaches

d. grafts are later removed by debriding procedure

13.A client who took a camping vacation two weeks ago in a country with

a tropical climate comes to the clinic describing vague symptoms and

diarrhea for the past week. Which finding is most important for the

nurse to report?

a. jaundice sclera

b. intestinal cramping

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c. weakness and fatigue

d. weight loss

14.During a home visit the nurse assesses the skin of a client with

eczema who reports than an exacerbation of symptoms has occurred

during the last week. Which information is most useful in determining

the possible cause of the symptoms?

a. an old friend with eczema came for visit

b. recently received an influenza immunization

c. corticosteroid cream was applied to eczema

d. a grandson and his new dog recently visited

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15.When explaining dietary guidelines to a client with acute

glomerulonephritis (AGN) which instruction should the nurse include in

the dietary teaching?

a. select a protein rich food daily

b. restrict sodium intake

c. eat high potassium foods

d. Avoid foods high in carbohydrate

16.A male client who is 24hr post operative for an exploratory

laparoctomy complains that he is starving because he has had no real

food since before surgery. Prior to advancing his diet which

intervention should the nurse implememt?

a. discontinue intravenous therapy

b. Assess for abdominal distension and tenderness

c. Obtain a prescription for a diet change

d. Auscultate bowel sound in all four quadrants

17.A client diagnose with stable angina secondary to ischemic heart

disease has a prescription for sublingual (SL) nitroglycerin (NTG). The

nurse should tell the client to follow which instructions if chest pain is

not relieved after taking 3 NTG tables 5 min apart?

a. drive to the nearest emergency department

b. take another NTG SL tablet and lie down until angina subsides

c. call primary healthcare provider

d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg

18.After taking orlistat (Xenical) for one week a femela client tells the

home health nurse that she is experiencing increasingly frequent oily

stools and flatus. What action should the nurse take?

a. obtain stool specimen to evaluate for occult blood and fat

content

b. instruct the client to increase her intake of saturated fats over

the next week

c.

d.

advice the client to stop taking the drug and contact the healthcare

provider

a.

b.

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ask the client to describe her dietary intake history for the last

several

days

c.

19.Two days after an abscess of the chin was drained the client returns to

the clinic with fever chills and a maculopapular rash with pruritis. The

client has taken an oral antibiotic and cleansed the wound today with

provide iodine (Betadine) solution. Which intervention should the nurse

implement first?

a. determine if the client has a history of diabetes

b. assess airway patency and oxygen saturation

 c. review recent medication history and allergies

(POSSIBLE ANSWER TOO)

d. obtain samples for complete blood count and cultures

20.A client experiences an ABO incompatibility reaction after multiple

blood transfusions. Which finding should the nurse report immediately

to the health care provider?

a. low back pain and hypotension

b. rhinitis and nasal stuffiness

c. delayed painful rash with urticarial

d. arthritic joint changes and chronic pain

21.A young adult male who has had type 2 diabetes mellitus (DM) is

admitted to the intensive care unit with hyperglycemic nonketotic

syndrome (HHNS). A sliding scale protocol for an isotonic IV solution

with regular insulin is prescribed based on the results of a continuous

blood glucose monitoring device that is attached to the client’s central

venous catheter. When the client’s respirations become labored and

his lungs sound indicate crackles what action should the nurse take?

a. collect a specimen for a white blood cell count and cultures

b. determine the clients glycosylated hemoglobin (A1C) (POSSIBLE

ANSWER)

c. administer insulin IV push until the clients fluid volume is

adjusted

d. decrease infusion rate to address fluid overload

22.When preparing to apply a fentanyl (Duragesic) transdermal patch the

nurse notes that the previously applied patch is intact on the client’s

upper back and the client denies pain. What action should the nurse

take?

a. Remove the patch and consult with the healthcare provider

about the client pain resolution

a.

b.

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c.

b. Place the patch on the clients shoulder and leave both patches in

place for 12 hours

c. Administer an oral analgesic and evaluate its effectiveness

before applying a new patch

d.

23.A client who had a myocardial infarction is admitted to the coronary

critical care unit (CCU) with a nitroglycerin drip infusing. The clients

last blood pressure measurements was 78/36.What action should the

nurse implement?

obtain blood pressure q5 minutes using duranap machine

change the dilution of the nitroglycerin infusion

reduce the rate of the nitroglycerin infusion

d. begin dopamine infusion at 5mcg/kg per minute

24.An adolescent is admitted to the hospital because of a suicide attempt

with an overdose of acetaminophen (Tylenol). Which blood values are

most important for the nurse to monitor during the first 72 hours

following ingestion of this overdose?

a. BUN creatinine specific gravity

b. White blood count, hemoglobin hematocrit

c. PH,PCO2, HC03

d. LDH OR LD, SGOT OR ALT, SGPT OR AST

25.An elderly post-operative female client is receiving morphine sulfate

via a PCA pump. Which assessment finding should prompt a nurse to

administer the prescribed PRN medication naloxone?

a. her respiratory rate is 7 breath/minute

b. she indicates that she feels as if she cannot get enough air to

breath

c. she has intercostal retractions and bilateral wheezing is

auscultated

d. her pulse oximeter is 89% on room air

26.Which assessment finding indicates to the nurse that the muscarinic

agent bethanechol (Urecholine) is effective for a client diagnose with

urinary retention?

a. urinary output equal to intake

b. no terminal urinary dribbling

a.

b.

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Apply a new patch in a different location after removing the

original patch

c.

c. denies stress incontinence

d. absence of xerostomia

27.Following involvement in a motor vehicle collision, a middle aged adult

client is admitted to the hospital with multiple facial fractures. The

client’s blood alcohol level is high on admission. Which PRN

prescription should be administer if the clients begins to exhibit signs

and symptoms of delirium tremens (DT s)?

a. Lorazepam (Ativan) 2mg IM

b. Chlorpromazine (thorazine) 50 mg IM

c. Prochlorperazine (Compazine) 5 mg IM

d. Hydromorphone (Dilaudid) 2 mg IM

28.Which instructions should the nurse include in the teaching plan of a

client who is taking the diuretic spironolactone (Aldactone)?

call the healthcare provider f you develop gynecomastia

Take the medication in the morning

a.

b.

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c.

Avoid caffeine and smoking

d. Increase your consumption of bananas and oranges

29.A glucagon emergency kit is prescribed for a client with type 1

diabetes mellitus. When should the nurse instruct the client to take the

glucagon?

a. after meals to increase endogenous insulin secretion

b. after insulin administration to prevent hypoglycemia

c. when recognized signs of severe hypoglycemia occur

d. when unable to eat during sick days

30.A client with hyperthyroidism is being treated with radioactive iodine

(I131). Which explanation should be included in preparing this client

for this treatment?

a.

b. explain

the need for using lead shields for 2 to 3 weeks after the treatment

c. describe the signs of goiter because this is a common side

effects of radioactive iodine

d. explain that relief of the signs/ symptoms of hyperthyroidism will

occur immediately

31.A female client is being treated for tuberculosis with rifampin (rifadin)

which statement indicates that further teaching is needed?

a. I will take my usual contraceptive for birth control

32.A client is discharged with a prescription for warfarin (Coumadin).

What discharge instructions should the nurse emphasize to the client?

a. take a multi vitamin supplement daily

b. use an astringent for superficial bleeding

c. avoid going barefoot especially outside

d. include large amounts of spinach in the diet

33.In caring for a client with diabetes insipidus who is receiving an

antidiuretic hormone intranasal which serum lab test is most important

for the nurse to monitor?

a. osmolality

b. calcium

c. platelets

d. glucose

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describe radioactive iodine as a tasteless, colorless medication

administered by the healthcare provider

34.After administering dihydroergotamine (Migranal) 1 mg

subcutaneously to a client with a severe migraine headache the nurse

should explain that relief can be expected within what time frame?

a. 2 hours

b. 5 minutes

c. 1 hour

d. 15 minutes

35.A client with hypertension who has been taking labetalol for two

weeks, reports a five pound (2.2 kg) weight gain. Which follow up

assessment is most important for the nurse to obtain?

a. capillary refill

b. body temperature

c. muscle strength

d. breath sounds

36.A male client is receiving pilocarpine hydrochloride (Isopto Carpine)

ophthalmic drops for glaucoma. He calls the clinic and ask the nurse

why he has difficulty seeing at night. What explanation should the

nurse provide?

a. The eye drops slow pupil response to accommodate for darkness

b. The drops increase the fluid in the eyes and cloud the visual field

( possible answer)

c. The drug can cause lens to become more opaque

d. The medication causes pupils to dilate which reduces night vision

37.A client who is taking and oral dose of tetracycline complains of

gastrointestinal upset. What snack should the nurse instruct the client

to take with the tetracycline?

a. toasted wheat bread and jelly

b. cheese and crackers

c. cold cereal with skim milk

d. fruit flavored yogurt

38.The therapeutic effect of insulin in treating type 1 diabetes mellitus is

based on which physiologic action?

a. Facilitates transport of glucose into the cell

b. Increases intracellular receptor site sensitivity

c. Stimulates function of beta cells in the pancreas

d. Delays carbohydrates digestion and absorption

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39.The health care provider prescribe a medication for an older adult

client who is complaining of insomnia. And instructs the client to return

in 2 weeks. The nurse should question which prescription?

a. Eszoplicone (Lunesta)10 mg orally at bed time

b. Zolpidem 10 mg orally at bed time

c. Temazepan orally at bed time

d. Ramelteon orally at bedtime

40.A male client reports to the nurse that he is experiencing GI distress

from high dose of a corticosteroid and is planning to stop taking the

medication. In response to the client’s statement what nursing action

is most important for the nurse to take?

a. Encourage the client to take medication with food to decrease GI

distress

b.

c. Review the

clients dosing schedule to ensure he is taking the prescribed amount

d. Assess the client for other indication of adverse effects of

corticosteroid

41.Fifteen minutes after receiving sulfa athenozole. A male client report a

burning sensation over his abdomen chest and groin. Which

intervention is most important for the nurse to implement?

a. Auscultate lung sounds for wheezing

b. Review the clients list if drugs allergies

c. Add sulfamethinozole to clients allergies

d. Check neurological vital signs

42.Antibiotic resistant organism are a major infection control problems. To

help minimize the emergence of resistant bacteria what instruction

should the nurse provide to the clients?

a. stop taking prescribed antibiotics when symptoms decrease

b. avoid using antibiotics when suffering from colds or the flu

c. ask the healthcare provider to prescribe the newest antibiotic

when needed

d. request a prescription for first time vancomysin for a sore throat

43.A client with symptoms of influenza that started the previous day ask

the clinic nurse about taking oseltamivir (Tamiflu) to treat the infection.

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Advice the client that the medication should be stopped

gradually rather than abruptly.

Which response should the nurse provide?

a. Advise the client once symptoms occur is too late to receive an

influenza vaccination

Refer the client to the healthcare provider at the clinic to obtain

a medication prescription

b.

c. Explain to the client that antibiotics are not useful in treating

viral infections such as influenza

d. Instruct the client that over the counter medications are

sufficient to manage influenza symptoms

44.Twenty minutes after the nurse starts a secondary IV infusion of

cafepime (maxipime) 2 grams using an infusion pump to deliver the

dose in one hour, the client reports feeling nauseated. What action

should the nurse implement?

a. stop medication infusion and notify the healthcare provider of

the adverse effect

b. increase the rate of the infusion to complete the dose of the

medication more rapidly

c.

d. reassure the client

that the nausea is not related to the iv infusion

45.The nurse administer donepezil hydrochloride (Aricept) to a client with

Alzheimer’s disease as an intervention for which client problem?

a. fluid volume excess

b. disturbed thought processes

c. chronic pain

d. altered breathing patterns

46.To prevent deep vein thrombosis following knee replacement surgery,

an adult male client is receiving enoxaparin (Lovenox) subcutaneously

daily.

Which laboratory finding requires immediate action by the nurse?

a. blood urea nitrogen (BUN) 20mg/dl or 7.1 mmol/L (SI)

b. Hematocrit 45%

c. Serum creatinine 1.0 mg/dl or 88.4 mol/L (SI)

d. Platelet count of 100,000/mm3 or 100x10??/ L (SI)

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continue the infusion and administer a prn antiemetic

prescription

47.A client with type 2 diabetes mellitus is managed with metformin

(Glucophage), an oral hypoglycemic agent. The primary health care

provider prescribes ad additional medication injected exenatide

(byetta).

Which information is most important for the nurse to teach this client?

a. Administer subcutaneously after meals

b. Consume additional sources of potassium

c. Notify the healthcare provider if anorexia occurs

d. Watch for signs of jitteriness or diaphoresis ( POSSIBLE ANSWER)

48.A client is who is diagnose with schizophrenia receives a prescription

for an atypical antipsychotic drug aripipazole (Abilify). Which

assessment should the nurse perform to monitor for an adrenergic

receptor antagonist side effect that commonly occurs atypical

antipsychotic agents?

a. observe the client hallucinatory behaviors

b. obtain the client finger stick glucose levels

c. measure the clients lying and standing blood pressure

d. determine the clients abnormal involuntary movements scale

(AIMS)

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1- A client with pheocromocytoma reports the onset of a severe

headache. The nurse observes that the client is very diaphoretic. Which

assessment data should the nurse obtain first?

Blood pressure

2- The drainage in the chest tube of a client with emphysema has

changed fromclear watery fluid. What action would be best for the nurse to

take/

Maintain the current IV antibiotic schedule

3- A client is admitted with a sudden onset of right sided the nurse

complete first?

Observe for peripheral edema

4- When planning care for a client newly diagnose with open angle

glaucoma, the nurse identifies a priority nursing diagnosis of “ Visual

sensory/perceptual alterations”. This diagnosis is based on which etiology?

Decreased peripheral vision

5- A client in the operating room received succinylcholine. The client is

experiencing muscle rigidity and has an extremely high temperature. What

action should the nurse implement?

Call the PACU nurse to prepare for prolonged ventilatory support

Also know that PACU is BP, Respiration and Pulse

6- A client who is receiving packed red blood cells develops nausea and

vomiting. What action should the nurse take first?

Stop the infusion of blood

Te lo pueden poner como hemodialysis y tambien es STOP transfusion 7-

A client with type 2 diabetes mellitus is admitted to the hospital for

uncontrolled DM. Insulin therapy is initiated with initial dose of Humulin

insulin at 8:00 at 16:00 the client complains of diaphoresis, rapid heart

beat, and feeling shaky. What should the nurse do first?

Determine the client current glucose level

8- After suctioning the patient with an endotracheal tube, which

assessment finding indicates to the nurse that the intervention was

effective?

Increase in breath sounds

9- The nurse observes an increase number of blood clots in the drainage

tubing of a client with continuous bladder irrigation following a transurethral

resection of the prostate (TURP). What is the best initial nursing action?

Provide additional oral fluid intake

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Also with TURP you must know that 3l of water a day is needed

10- Which nursing diagnosis should be selected for a client who is

receiving thrombolytic infusions for treatment of an acute myocardial

infarction?

Risk for injury related to effects of thrombolysis

11- The nurse is assessing a client who has returned from surgery following

a thoracotomy. Which finding indicates the client is experiencing adequate

gas exchange?

The client demonstrates effective coughing and deep breathing exercises 12-

When caring for a client with nephrotic syndrome which assessment is most

important for the nurse to obtain?

Daily Weight

13- A client who had a biliopancreatic diversion procedure (BOP) 3 months

ago is admitted with severe dehydration. Which assessment finding

warrants immediate intervention by the nurse?

Gastroccult positive emesis

14- A female client with possible acute renal failure (ARF) is admitted to the

hospital and mannitol (Osmitrol) is prescribed as a fluid challenge. Prior

to carrying out this prescription, what intervention should the nurse

implement?

• No specific nursing action is required

• Instruct the client to empty the bladder

• Collect a clean catch urine specimen

• Obtain vital signs and breathe sounds

15- The nurse positions a male client for a lumbar puncture by placing him in

the side-lying position with his knees flexed and pulled toward his trunk.

What action should the nurse implement next?

• Call another nurse to assist the healthcare provider

• Provide a small pillow for the client to curl around

• Instruct the client to perform a Valsalva maneuver

• Support the client’s head bent forward to the chest

16- When teaching a client with osteoporosis to increase weight-bearing

exercise, how should the nurse explain the purpose of this activity?

• Strengthen leg muscles

• Promote venous return

• Increase bone strength

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• Restore range of motion

17- A male tells the clinic nurse that he is experiencing burning on urination,

and assessment that he had sexual intercourse four days ago with a

woman he casually met. Which action should the nurse implement?

• Observe the perineal area for a chancroid-like lesion

• Obtain a specimen of urethral drainage for culture (POSSIBLE

ANSWER)

• Identify all sexual partners in the last four days

• Assess for perineal itching, erythemia, and excoriation

18- An older female client with long term type 2 diabetes mellitus (DM) is

seen in the doctor routine health assessment. To determine if the client is

experiencing any long-term complications of DM, which assessments

should the nurse obtain? Select all that apply:

• Visual acuity

• Serum creatinine and blood urea nitrogen (BUN)

• Signs of respiratory tract infection • Sensation in feet and legs

• Skin condition of lower extremities

19- Which laboratory test result is most important for the nurse to report to

thesurgeon prior to a client’s scheduled abdominal surgery?

• Potassium level of 4 mEq/liter

• Blood glucose of 90 mg/dl

• Serum creatinine of 5 mg/dl (POSSIBLE ANSWER)

• Hemoglobin level of 13 grams

20- A client who has a history of long-standing back pain treated with

methadone (Dolophine), is admitted to the surgical unit following

urological surgery. What modifications in the plan of care should the

nurse make for this client’s pain management during the postoperative

period?

• Use minimal parenteral opioids for surgical pain, in addition to

oral methadone

• Maintain client’s methadone, and medicate surgical pain based

on pain rating

• Consult with surgeon about increasing methadone in lieu of

parenteral opioids

• Make no changes in standard pain management for this surgery

and hold methadone

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21- The nurse applies an automatic external defibrillator (AED) to a client

who collapsed in an exam room at a community clinic. What action

should the nurse take next?

• Determine the defibrillator reading

• Assess the client’s oxygen saturation

• Bring a crash cart to the exam room

• Measure the client’s blood pressure

22- Which change in lab values would indicate to the nurse that treatment

for gout is successful?

• Decreased serum uric acid

• Decreased serum purine

• Increased serum uric acid

• Increased serum purine

23- The nurse reports that a client is at risk for a brain attack (stroke)

finding?• Jugular vein distention

• Palpable cervical lymph node

• Carotid bruit

• Nuchal rigidity

24- The nurse is assessing a group of older adults. What factor in a male

client’shistory puts him at greatest risk for developing colon cancer?

• Is excessively exposed to sunlight

• Eats a high-fat diet

• Smokes cigars (POSSIBLE ANSWER)

• Has intestinal polyps

25- While taking routine vital signs at 0400 AM, the nurse notes that a client

who had a total knee replacement the previous day has a heart rate of

126 beats/minute. What action should the nurse take first?

• Compare heart rate trends with blood pressure trends ( POSSIBLE

ANSWER)

• Review the medical record for a history of cardiac disease

• Check surgical drainage system and bandage for bleeding

• Determine current pain level using a 10-point scale

26- A client who suffered an electrical injury on the left foot is admitted to

the burn include in this client’s plan of care? (incomplete)

• Assess lung sounds q4 hours

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• Perform passive range of motion

• Evaluate level of consciousness

• Continuous cardiac monitoring

27- The nurse is taking a client’s blood pressure sphygmomanometer cuff is

inflated. What (incomplete)

• Administer a prescribed PRN antianxiety (POSSIBLE ANSWER)

• Assess the client’s recent serum calcium

• Notify the healthcare provider of the

• Prepare to implement seizure precautions

28- A client with eczema is using an over-the-counter (OTC) topical product

with urea 10% OTC (Aqua Care Cream) to the affected skin areas. Which

finding reflects the expected therapeutic response?

• Decreased weeping of ulcerations in affected area (POSSIBLE

ANSWER)

• Healing with a return to normal skin appearance

• Reduced pain in eczematous areas

• Hydration of affected dry skin areas

29- During an annual health check, the clinic nurse updates an adult female’s

health history. When discussing the woman’s history of lactose

intolerance, the client reports that it has been years since she last

consumed dairy products. What dietary suggestions should the nurse

recommend to help ensure that the client receives an adequate intake of

calcium? Select all that apply:

• Increase intake of salmon, sardines, tofu, and leafy green vegetables

• Sip a half-cup of mil during a mid-day meal at least every other day

• Eat at least six servings of citrus fruits weekly

• Include 2 to 3 servings of yellow and green squash weekly

• Take a calcium supplement with vitamin D daily

30- A healthcare worker with no known exposure to tuberculosis has received

aMantoux tuberculosis skin test. The nurse’s assessment of the test after

72 hours indicates 5mm of erythema without induration. What is the best

initial nursing action?

• Review client’s history for possible exposure to TB

• Instruct the client to return for a repeat test in 1 week

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• Refer client to a healthcare provider for isoniazid (INH) therapy

• Document negative results in the client’s medical record

31-A male client in skeletal traction tells the nurse that he is frustrated

because he needs help repositioning himself in bed. Which intervention

should the nurse implement?

• Inform the client that it is the nurse’s responsibility to reposition

• Provide an overhead trapeze to the bed for the client to use

• Place a draw sheet under the client to assist with repositioning

• Administer an intravenous PRN anti-anxiety medication

32-In planning care for a client with pneumonia, which nursing problem

should the nurse identify as the priority?

• Impaired gas exchange related to the effects of alveolar-capillary

membrane changes

• Acute pain related to the effects of inflammation of the parietal

pleura

• Deficient fluid volume related to fever, infection, and increased

metabolic rate

• Disturbed sleep pattern related to pain, dyspnea, and

hospitalization

33-A hospitalized client with chemotherapy-induced stomatitis complains of

mouth pain. What is the best initial nursing action?

• Encourage frequent mouth care

• Administer a topical analgesic per PRN protocol

• Cleanse the tongue and mouth with glycerin swabs

• Obtain a soft diet for the client

33- A client returns from surgery following a hiatal hernia repair via Nissen

fundoplication. Which position should the nurse implement for this client?

• Right side-lying to promote stomach emptying

• Prone to apply external pressure to the suture line

• Left side-lying to reduce stress on the suture line

• 30 degree semi-Fowler’s to drop the diaphragm

34- An adult woman with Grave’s disease is admitted with severe

dehydration iscurrently restless and refusing to eat. Which action is most

important for the nurse to implement?

• Keep room temperature cool

• Determine the client’s food preferences

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• Maintain a patent intravenous site

• Teach the client relaxation techniques

35- The nurse admits a client who has a medical diagnosis of bacterial

meningitis to the unit. Which intervention has the highest priority in

providing care for this client?

• Administer initial dose of broad-spectrum antibiotic

• Instruct the client to force fluids hourly

• Obtain results of culture and sensitivity of CSF

• Assess the client for symptoms of hyponatremia

36- A client uses triamcinolone (Kenalog), a corticosteroid ointment, to

manage pruritis caused by a chronic skin rash. The client calls the clinic

nurse to report increased erythema with purulent exudate at the site. What

action should the nurse implement?

• Schedule an appointment for the client to see the healthcare

provider

• Advise the client to apply plastic wrap over the ointment to

promote healing

• Explain that the client needs to complete all prescribed doses of

the medication

• Instruct the client to continue the ointment until all erythema is

relieved

37- During a paracentesis, two liters of fluid are removed from the

abdomen of a client with ascites. A drainage bag is placed, and 50 ml of

clear, straw-colored fluid drains within the first hour. What action should the

nurse implement?

• Palpate for abdominal distention

• Clamp drainage tube for 5 minutes

• Continue to monitor the fluid output

• Send fluid to the lab for analysis

38- The nurse assesses the dressing of a client who has just returned from

post-anesthesia and finds that the dressing is wet with a moderate amount

of bright red bloody drainage. What action should the nurse take?

• Replace dressing with a new sterile dressing, and monitor the

wound hourly until bleeding is stopped

• Call surgery and request that the surgeon see the wound prior to

leaving the hospital

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• Reinforce the dressing and document that a moderate amount of

sanguineous drainage was on the dressing

• Document that the dressing was saturated with serious drainage,

and do not change the dressing

39- While the home health nurse is making a home visit, a client with a

history of seizures demonstrates tonic-clonic seizure activity. What action

should the nurse implement first?

• Direct a family member to call emergency services

• Ascertain the trigger event

• Protect the client’s head with a pillow

• Observe the postictal breathing pattern

40- A client who weighs 176 pounds is admitted to the intensive care unit

with a serum glucose level of 600 mg/dl and a serum acetone level of 50

mg/dl. Regular insulin at a rate of 0.1unit/kg/hour is prescribed. The

pharmacy provides a solution of Regular insulin 100 units/100 ml of normal

saline. The nurse should set the infusion pump to deliver how many ml/hour?

(Enter numeric value only) = 8ML/H

41- A client whose history includes IV drug abuse is admitted to the

intensive care unit (ICU) with Kaposi’s sarcoma associated with Acquired

Immune Deficiency Syndrome (AIDS). Which intervention is most important

for the nurse to include in the client’s plan of care?

• Observe for adverse medication reactions

• Assess for signs of AIDS dementia

• Identify signs of opportunistic infections

• Locate local HIV support groups

42-(Photo) The charge nurse observes a newly employed nurse gathering

equipment to obtain a venous blood sample from a client’s implanted port.

The nurse has obtained the equipment seen in the photo. What actions

should the charge nurse take? (Select all that apply)

• Guide the nurse in inserting the needle at a 45 degree angle

• Remind the nurse to wear sterile gloves for this procedure

• Instruct the nurse to obtain several red-topped tubes

• Determine if the nurse has ever performed this skill

• Assist in obtaining the correct needle to access the port

43- After a computer tomography (CT) scan with intravenous contrast

medium, a client returns to the room complaining of shortness of breath and

itching. Which intervention should the nurse implement?

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A. Send another nurse for an emergency tracheotomy set

B. Call respiratory therapy to give a breathing treatment

C. Review the client's complete list of allergies

D. Prepare a dose of Epinephrine (Adrenalin

44- The nurse is reviewing blood pressure readings for a group of client's

on a medical unit. Which client is at the highest risk for complications related

to hypertension?

A. Young adult Hispanic female who has a hemoglobin of 11 gm and

drinks beer every day

B. Middle-aged African-American male who has a serum creatinine

level of 2.9 mg/dL

C. Older Asian male who eats a diet consisiting of smoked, cured,

and pickled foods.

D. Post-menopausal Caucasian female who overeats and is 20%

above ideal body weight

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1. Shingles

- Teach the pt about phantom pain

2. Shingles Select all the apply

- pain

- ability

- skin integrity

3. PATIENT W/ EZCEMA APPLYING CREAM TTO IS WORKING:

- HEALING WITH A RETURN SKIN TO NORMAL APPEARANCE.

4. PT WITH OBESITY HIGH GLUCOSE LEVEL IS AT RISK FOR?

- CARDIOVASCULAR DISEASE

5. FOR ANEMIA WHAT DOESN’T HAVE IRON, WHICH FOODS ARE NOT RICH

IN IRON?

- NO ORANGE

6. PT. W/ RISK OF DVT

- PERFORM ROM EXERCISES ALSO LEGS EXERCISE CAN BE OTHER

WAY TO ANSWER

7. DISCHARGE FOR VENOUS ULCERS SELECT ALL APPLY? - ELEVATE

THE FEET WHEN LAYING DOWN

- CHECK BROWNISH SKIN AROUND THE ANKLES

- VITAMINS

8. PT W/ SIADH:

- HARD CANDY FOR THIRST.

9. PT ARRIVE TO PACU POSTOP MOANING WHAT TO DO: - CHECK

PULSE, BP AND RESPIRATIONS.

10.Pt. DIAGNOSED RECENTLY W/ DM HAVE NOT BEEN ABLE TO CONTROL

GLUCOSE LEVEL DURING 3 MONTH WHAT SHOULD BE DONE:

- CHECK FOR A1C LEVEL

- (OTHER SAY ASSESS FOR WHAT SHE HAVE BEEN EATING 3 DAYS

AGO).

11.WHEN BP IS HIGH

- ADMINISTER (LASIX)

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12.PATIENT W/ ESOPHAEGAL VARICES HAVE NOT BE BLEEDING FOR 3

DAYS:

- PROVIDE LUKE WARM BROTH, ICE TEA AND LEMON POPSICLE.

13.CALCULO:

- 0.75

14.PT WITH OSTEOMALCIA

- RISK FOR INJURY

15.SBAR—EXPLAIN SPECIFIC REASON FOR URGENT NOTIFICATON

- TEMPERATURE

16.INTESTINAL BOWEL OBSTRUCTION

- PLACE THE PT 90 DEGREES SITTING

17.OSTEOARTHRITIS

- RISK FOR INJURY RELATED TO JOINT PAIN

18.BONE CANCER TYPE IV:

- GIVE OPIODS- NON OPIODS ANALGESICS.

19.HYPOTHYROIDISM

- RESTRICT SODIUM NA 122

20.PT ARRIVES TO CLINIC W/ NUCHAL RIGIDITY FEVER FOR 6 HOURS

WHAT TO DO:

- PREPARE FOR ISOLATION PRECAUTIONS

- ( I PUT THIS ONE AND NO LUMBAR PUNCTURE)

21.INTERMITENT CLAUDICATION TEACHING

- BANDAGE ELASTIC WRAPED AROUND LEGS

- TAMBIEN PUEDE SALIR COMO PAIN TRACTION CAST NOTIFY MD

(CAST NO MORE THEN 4HR)

22.PREOPERATIVE NURSING CARE

- ASSESS EMOTIONAL PREPAREDNESS

- ALSO CAN BE CONCERNS AND ANXIETY FOR SURGERY DEPENDE

LA QUE PONGAN

23.TRACHESTOMY CARE:

- LEAVE OLD TIES ON UNTIL NEW ONES BE ON PLACE OR SECURE.

24.STERNAL TRACTION COMPLAINS OF PAIN

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- ADMINISTER PRN MEDS

25.EXTERNAL FIXATION

- ADMINISTER PRN MEDS

26.MULTIPLE SCLEROSIS (MS)

- ADMINISTER ANTIMEDICS/ PRN AS PRESCRIBED

27.FEMALE PATIENT HOW HAVE EPIGASTRIC PAIN FOR 3 DAYS HAVE BEEN

TAKIN ANTACIDS AND NO RESOLVE ARRIVE TO HOSPITAL W/HR;128

BPM, BP110/70 WHAT IS THE MOST IMPORTANT INTERVENTION FINDING

IN ASSESSMENT:

- ASSESS FOR RADIATING JAW PAIN.

28.Pt. W. RADIACTIVE THERAPY WHAT TO TEACH/ RECOMMEND TO -

PROTECT THAT PART OF THE SKIN SPECIALLY FROM THE SUN

29.Pt WITH ALS WHAT TO DO TO PREVENT RESPIRATORY COMPLICATIONS:

- TEACH BREATHING TECNIQUES, USES SPIROMETER, AUSCULTATE

FOR BREATH OR LUNG SOUNDS.

30.PT WITH LEFT LEF ULCER:

- KEEP LEG ELEVATED AS MUCH AS HE CAN.

31.PT WITH AN EXTERNAL DEVICE COMPLAINING OF PAIN:

- ASSESS FOR PHERIPHERAL PULSES.

32.CALCULATION 1G/0.4 G

- = 2.5

33.EXAMPLES OF DASH DIET:

- PEEL FRUITS AND VEGETABLES.

34.CHEST TUBE W/ A DRAINAGE CHANGING FROM CLEAR TO

GREEN: -KEEP IV FLUIDS.

35.PT W/ OPEN ANGLE GLAUCOMA SELECT ALL THAT APPLY:

- FREQUENT EYE EXAM TO ASSES FOR VISSION,

- USE DROPS TO DIMINSH IOP,

- AVOID EXTRENOUS EXERCICES LIKE JOGGING OR RUNNING -

( YO PUSE SOLO ESAS 3 RESPUESTAS).

36.PT W/ HYPERTHYROIDISM DEVELOPING EXOSPHTALMUS:

- PRESCRIBE TEAR EYE DROPS.

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37.PT VOMITING BLOOD LIKE THE PICTURE SAME AS

HEMATENSIS: -CHECK VITAL SIGNS ( ASI ESTA EN TODOS

LOS PAPELES)

- AUSCULTATE LUNGS SOUNDS ( FUE LO QUE PUSO YADIRA)

38.PATIENT W/ ML FELL AND WHEN RECEIVING THE NURSE HE HAVE

2 PROJECTILE VOMITS WHAT SHE DO: - PROVIDE ANTIEMETICS

PRN .

39.PT W/ RAYNAUD SYNDROME WHICH WORK AS A DATA ENTRY CLERK: -

PROVIDE A SPACE TO WARM THE ENVIROMENT NEXT TO HER

- ( ALGO ASI ERA LA RESPUESTA). Y HAY OTRA RESPUESTA QUE

SOLO DICE KEEP MONITORING

40.PATIENT THAT HAVE THE K= 6.7 WHAT MEDICATION PROVIDE: -

KAYELAXATE (TREATS HYPERKALEMIA).

41.COLON CANCER PT

- KAYELAXATE Med

42.RENAL INJURY

- KAYELAXATE MED

43.PT WITH A BRONCHOSCOPY AND DRINK A GLASS OF JUICE :

- DELAY THE PROCEDURE 6 HOURS

44.NEW PATIENT DIAGNOSES WITH DM TYPE IS RECEIVING TEACHING IN

WHICH GLUCOMETER WILL BE THE BEST:

- ASSESS FOR VISUAL ACUITY AND ABILITY TO READ OR

SOMETHING LIKE THAT.

45.ABG (PH 7.25 PCO2 50 SODIUM 60 -

TACHY AND CONFUSION/ RESPIRATORY

46.ACUTE AGN DIET:

- RESTRICT NA INTAKE.

47.PT W/ A EXPRESSIVE APHASIA IS ANGER WHAT SHOULD DO THE

NURSE:

- CVA- COMMUNICATE W/ PICTURE BOARDS.

48.NURSE IS TEACHING THE WIFE IF A PATIENT DIAGNOSED W/ SEIZURE

WHAT TO DO:

- TEACH HER HOW TO POSITION HIM

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49.PT AFTER TTO OF SOMETHING AND WANTS TO EAT:

- NURSE ASSESS FOR BOWEL MOVEMENTS.

50.SLE:

- ASSESS FOR HEMATURIA

51.PATIENT ALLERGIC TO BANANA (LATEX):

- CALL TO MD AND OR STAFF TO BE CHANGE EVERYTHING FOR

SINTHETIC MATERIALS,

52.SUBCUT EMPHYSEMA- TORACOTOMY WAS A SELECT ALL THAT APPLY:

- ASSESS FOR LUNG SOUNDS,

53.NECK DISTENTION

- THINK IT WAS AND OTHER CHOICE THAT I NOT REMEMBER NOW.

54.RESTLESS LEG SYNDROME CON

FEOSOL: - ASSESS FOR IRON

AND FERRITIN.

55.BNP

- ADMINISTRATIVE FUROSEMIDE LASIX IV

56.PARKINSON PT WALKING

- REASURE THAT STEPPING ON CRACKLES IS NOT HARMFUL

57.ADDISON DISEASE

- TAKE CORTICOSTEROID MEDS

58.CARPO TONIC SYNDROME

- WEAR BRACE IN BOTH WRIST

59.PARKINSON AND ALZAIMERS PT

- TATICARDIC AND CONFUSION

60.MID ABDOMEN BURNING PAIN

- PEPTIC ULCER

61.ANTIBIOTICS

- CLEAR DRAINAGE IMPROVE

62.ALLOPRINOL FOR GOUT

- TAKE MEDS ALWAYS

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63.BLOOD TRANSFUSION HIGH TEMPERATURE

- BACK PAIN AND HYPOTENSION

- ( ABO- LOW BACK PAIN AND HYPOTENSION)

64.CENTRAL FALL RISK

- CARDIOVASCULAR DISEASE

65.RIGHT HIP FRACTURE

- O2 SAT LEVEL

66.DESCRIBE PAIN NEUROPATHY

- NERVOUS SYSTEM

67.ACUTE ABDOMINAL PAIN, NASUA, PROJECTIBLE VOMITING

- SEVERE HEADECHE AND PHOTO Sensitivity

68.UROLITHISIS O LITHOTRIPSY PROCEDURE

- RESTRICT PHYSICAL ACTION

69.UAP ( DICE EL PACIENTE QUE TIENE ABD PAIN LARGE TARRY STOOL

- TEST STOOL FOR OCCULT BLOOD

70.Insulin for a glucose level of 255 (Pte tmeblando despues que le

pusieron insulin.)

- Obtain capillary glucose.

71.NGT proper tube procedure -

Elevate dead 60 to 90

degree….

72.RA (rheuma)

- Impaired peripheral mobility relate to join pain.

73.Finger stick glucose finding 50

- OC Level of conscious

74.BMI (una persona que pueden tener colon cancer)

- Large waist circumference with central fat

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g

Review for Hesi: Recopilation:

1. Community Health/Geriatrics/Professional Issues-Leadership-Geriatric syndrome-home health

RN needs to go 4 patients and which one needs to see first:

A. The patient discharge yesterday and dehydrated

B. The patient start a new medication and is incontinence

C. The patient that doesn’t want to take a shower

2. Community Health/Medical Surgical-Renal/Reproductive-TURP-home care

The nurse is reinforcing home care instructions with a client who is being

discharged following transurethral resection of the prostate (TURP). Which

intervention is most important for the nurse to include in the clients

discharge instructions?

A- Avoid strenuous activity for 6 weeks

B- Report fresh blood in the urine

C- Take acetaminophen for fever 101

D- Consume 6 to 8 glasses of water daily

3. Community Health/Pediatrics/Professional IssuesLeadership/Legal/Ethical-School nurse role

The school nurse is implementing standards to manage students and provide

a safe and healthy school setting. Which action is most important for the

nurse to implement?

A- Maintain student immunization records

B- Develop an emergency plan for the school

C- Ensure that medical supplies are available

D- Conduct annual student health assessments

4. Community Health/Psychiatric/Mental Health/Fundamentals/Professional Issues/Medical

SurgicalAnxiety/Communications/Basic Nursing Skills/Safety/TeachingInfection-communication

A pt with possible pneumonia come to the hospital and the nurse need to do

an assessment but the family don’t want to leave the room, what the nurse

need to do first?

A –Call the security

B Put the family out of the room

C Put a pneumonia droplet sign in the door

D – Continue with the assessment and put mask to the family

5. Critical Care/Fundamentals-Med Administration/Math-IV-mcg/mindopamine

DOPAMINE 198 LBS 7mcg/kg/minute, 500 mg and 400 ml. ml/hour?

Answer: 47

198:2.2=90

7x60x90=37800mcg

37800mcg:1000 to mlg=37.8 mlg

500mg:400ml=1.25

37.8:1.25=30.24

6. Critical Care/Fundamentals/Maternity/Pediatrics/Professional IssuesBasic Nursing

Skills/Nutrition/Antepartum/Leadership-Communityprimary prevention

A public health nurse receives funding to initiate a primary prevention

program in the community. Which program best fits the nurse’s proposal?

A. Case management and screening for clients with HIV.

B. Regional relocation center for earthquake victims.

C. Vitamin supplements for high-risk pregnant women.

D. Lead screening for children in low-income housing.

7. Critical Care/Geriatrics/Medical Surgical-Renal-Acute Tubular Necrosis

-GERI

Diabetic,renal no function,decrease urine or not urine, septic shock,

check urine specific Gravity and osmolarity urine.

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Acute Renal Failure: Low Protein

Chronic Renal Failure: NOT Protein at all

Asw possible:Urine claude and check input and output

8. Critical Care/Medical Surgical-Cardiovascular?

Immune/Hematology/Integumentary/Respiratory-MODS-central line placement

NOTE: The Multiple Organ Dysfunction Syndrome (MODS) can be defined as

the development of potentially reversible physiologic derangement involving

two or more organ systems not involved in the disorder that resulted in ICU

admission, and arising in the wake of a potentially life-threatening physiologic

insult.

Answer: Shock

26. Fundamentals/Medical Surgical-Basic Nursing Skills-Fluid volume overload

After receiving IV fluids in the emergency department, an elderly client is admitted

to the acute care unit with a medical diagnosis of dehydration. The client is

receiving 0.9% normal saline at 125ml/hr. via a saline lock and has a bounding

pulse, tachycardia, and pedal edema. When contacting the healthcare provider, the

nurse anticipates a prescription for what intervention?

a. Decrease the rate of the normal saline infusion

b. Increase the rate of the normal saline solution

c. Change the IV solution to 0.45 saline solution

d. Remove the saline lock from the client’s arm

27. Fundamentals/Medical Surgical-Basic Nursing Skills/EliminationAcute abdominal pain

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Lower abdominal pain (Order):

1. POSITION BENT KNEES

2. Ask for last food that eat

3. DETERMINE BOWEL MOVEMENT

4. INSPECT ABDOMINAL

5. AUSCULTATE 4 QUADRANTS

28. Fundamentals/Medical Surgical-Basic Nursing Skills/NutritionParkinson’s-meals

Answer: Provide privacy and give extra time to eat meals and snack

OJO

The spouse of a client with Parkinson’s wants to know how to best assist her

husband during feeding as he is having "increasing problems with drooling and

swallowing." What instruction should the nurse provide to the family member?

A) "Use thickened liquids along with upright positioning during feeding."

B) "It might be time to switch to enteral feedings if you are afraid that your

husband may choke."

C) "Increase the amount of fluids he receives to decrease saliva formation and

improve swallowing."

D) "Use a straw during feedings to facilitate swallowing."

29.Fundamentals/Medical Surgical-Basic Nursing Skills/Nutrition-Visually impaired-feeding-UAP Reloj

posisiones manecillas

A patient with chemicals in the eyes and is in the hospital. What the nurse

tells to the UAP to do to help the patient with the food?

A- Give food to the patient in the mouth

B- Indicate to the patient where is the tray ( reorient )

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C- Look how the patient eat

D- Finger food

30. Fundamentals/Medical Surgical-Basic Nursing Skills/SafetyHuntington’s chorea

*ANSWER: padding on the side rail

Or llevarlo a la cafeteria

31. Fundamentals/Medical Surgical-Basic Nursing Skills/SafetyHyperglycemia-vomiting

TYPE 1 DIABETES MELLITUS BLOOD GLUCOSE 420 BEGINS

VOMIT:

A- TURN THE CLIENT TO A LATERAL position

B- OBTAIN A FINGER STICK GLUCOSE

32. Fundamentals/Medical Surgical-Basic Nursing Skills/Safety-MRI

A PATIENT SCHEDULED MRI AND SAID THAT HAS A METAL TOOTH.

WHAT THE RN NEED TO DO?

A- ASSESS PT FEAR TO THE TEST

B- CONSULTS

RADIOLOGY

C- SEND PT TO X-RAY INSTEAD DCANCEL THE TEST.

33. Fundamentals/Medical Surgical-Integumentary/Operative-JP drain full

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POSTOPERATIVE DRESSING: ABDOMINAL WOUND WITH

JACKSON PRATT DRAIN. WHAT THE NURSE DO FIRST? (PICTURE)

A- ASSESS THE SURGICAL WOUND

B- SQUEEZE

C- EMPTY

34. Fundamentals/Medical Surgical-Med Administration-IV-gravity infusion flow rate

(Question with 4 pictures) Overflow:

A- ARM

B- ARM AND FOREARM

C- IV

DRIP

D- IV REGULATION

35. Fundamentals/Medical Surgical-Med Administration/Math-IVHeparin-units

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HEPARIN SODIUM 25000 IN 5P0 ml

Answer: 36

36. Fundamentals/Medical Surgical-Renal-Diuretic & daily weight

Discharge teaching to a patient with heart failure what parameter is most

important for weight monitoring

*Answer: Weight the patient at the same time, Same Scale, same cloth type)

The nurse is preparing a teaching plan for a client taking a prescribed

diuretic for edema in the lower extremities. What instruction should the

nurse include in this teaching plan?

A- Stop taking the medication when the edema in the lower extremities subsides.

B- Take the diuretic every day, regardless of weight loss or muscle weakness.

C- Limit fluid intake while taking the diuretic to reduce fluid retention.

D- Weight yourself daily at the same time and report excessive weight loss.

37. Fundamentals/Pathophysiology-Basic Nursing Skills/Hygiene/SafetyHandwashing

HAND WASHING:

A- Reduces spread of microorganism. Bio…..

B- Lock virus

C- Lock in human virus

38. Fundamentals/Pathophysiology/Professional Issues/Medical SurgicalBasic Nursing Skills/Nutrition/Teaching-DM2 and CKD-diet

Ketoacidosis Diet

A- Banana, whole bread…

B- Oatmeal……

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C- 6 oz Coffee, strawberry, artificial sweeteningD-Egg, butter

39. Fundamentals/Pediatrics-Basic Nursing Skills/Nutrition-infant weight1-month

AT THE 1 MONTH OLD CLINIC VISIT, AN INFANTS NUDE WEIGHT IS 600

GRAM MORE THAT AT BIRTH. WHICH INTERVENTION SHOULD THE

NURSE IMPLEMENT?

A. ENCOURAGE GIVING 2 OUNCES OF WATER BETWEEN FEEDINGS.

B. RECOMMENDED ADING KARO SYRUP TO EACH FORMA FEEDING

C. DOCUMENT INFANT’S WEIGHT ON GROWTH CHART D. CHECK

THE INFANT’S WEIGHT USING A METRIC SCALE.

NOTE: ANSWER: 600 grams

40. Fundamentals/Pediatrics-Med Administration-Oral susp-resistingPEDI

A child that resists taking the medication:

a. Parents help the nurse holding him

b. Provide the child juice with the medication

c. Explain to the child that if he doesn’t take the medication, he won’t feel

better.

41. Fundamentals/Pediatrics-Med Administration/Math-Calculation-PO dose-3x/wk/BSA

The healthcare provider prescribes methotrexate 7.5 mg PO weekly, in 3

divided doses for a child with rheumatoid arthritis whose body surface area

(BSA) is 0.6 m2. The therapeutic dosage of methotrexate PO is 5 to 15

mg/m2/week. How many mg should the nurse administer in each of the

three doses given week?

Answer: 2.5

42. Fundamentals/Pediatrics-Med Administration/Math-IV-ml/hour-PEDI

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Vanco

400 mg 6 hours, 100 ml one and half hour

Answer: 67

43.

Un Nino que los Padres lo llevaron al ER

A. Mandarlo a la casa

B. RN ponerse el precautionC. Ponerle una

mascara al nino.

B

*(Isolated room)

* Airborne precautions:

1. Diseases

a. Measles

b. Chickenpox (varicella)

c. Disseminated varicella zoster

d. Tuberculosis

2. Barrier protection

a. Single room is maintained under negative pressure; door remains closed

except upon entering and exiting.

b. Negative airflow pressure is used in the room, with a minimum of 6 to 12 air

exchanges p hour depending on health care agency protocol.

c. Ultraviolet germicide irradiation or high-efficiency particulate air filter is

usedin the room

d. Health care workers wear mask or personal respiratory protection device.

e. Mask placed on client when client is out of the room; client leaves the room

only if necessary.

44.

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Fundamentals/Pediatrics/Professional Issues/Medical Surgical-Basic

Nursing Skills/Safety/Leadership-Airborne precautions

Fundamentals/Professional Issues-Basic Nursing

Skills/Nutrition/Cultural/Spiritual-Hindu

diet

A Hindu patient… what can the nurse do?

A- REMOVE BEEF FROM PT MEAL TRAIL

B- ENCOURAGE FAMILY TO BRING FOOD FROM HOME

C- SHOW THE CARDIAC MENU TO THE PATIENT

D- GIVE TO THE PATIENT WHAT HE WANTS

45. Fundamentals/Professional Issues-Med Administration/DocumentationBar code scan-med administration

When administering a new medication to a client, the nurse uses a scanner to

register the nurse?

A) Use the scanner to register the bar code on the client’s identification

bracelet.

B) Document the medication administration on the client’s computerized

record.

C) Remove the medication from the unit dose packaging while verifying the

dose.

D) Reconcile the medication to be administered with the initial client

prescription.

46.Fundamentals/Professional Issues/Medical Surgical-Basic Nursing

Skills/Nutrition/Teaching- Hypertension diet

A PATIENT WITH HIGH BP, THE NURSE GIVE A TEACHING FOR

WHAT CAN HE EAT FOR LUNCH?

A- TOMATO JUICE AND GLUTEN FREE CRACKERS

B- BAKED SWEET POTATO

47.

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Fundamentals/Professional Issues/Medical Surgical-Basic Nursing

Skills/Safety/Teaching-Influenza precautions

Patient with influenza. Dehydrated and pneumonia:

A. Droplet precaution

B. Family member wear mask

NOTE: Droplet precautions should be implemented for patients with

suspected or confirmed influenza for 7 days after illness onset or until 24

hours after the resolution of fever and respiratory symptoms, whichever is

longer, while a patient is in a healthcare facility.

48.

 Administration/Teaching-Insulin adm-teaching 1

(PICTURE)

The nurse shows the mom of the child how to use insulin for the child that is

diabetic:

A- ASSIST THE MOTHER IN

B- THE CORRECT ANGLE

C- LOCATING THE CORRECT SITE

Or assess

45 Angle

Pen 90 angle

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Fundamentals/Professional Issues/Medical SurgicalMed

49. Fundamentals/Professional Issues/Medical Surgical-Teaching-Pursed

lip breathing 2

VIDEO *Pursed lip Breathing: IN and OUT

(Inhale through the nose and exhale by mouth)

50. Geriatrics/Medical Surgical-Integumentary-Skin care-GERI

An older male resident of a long-term care facility has been scratching his legs for

the past 2 days. Which intervention should the nurse implement? A) Explain the

importance of bathing or showering daily.

B) Keep the legs covered as much as possible.

C) Apply emollient to affect area at least twice daily.

D) Encourage fluid intake of at least 2,000 ml daily.

51. Maternity–Antepartum –Fetal stress - Tachycardia

The nurse is assessing a primigravida at 39-weeks gestation during a weekly

prenatal visit. Which finding is most important for the nurse to report to the

healthcare provider?

A) Reports intermittent low back pain.

B) Fetal heart rate of 200 beats/minutes

C) Complains of early morning heartburn

D) Maternal hemoglobin of 11.0 g/ dl or 110 g/l (SI)

*Note: Normal FHR pregnant women: 120-160

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52. Maternity – Intrapartum – Intrapartum pain management

PREGNANT WOMEN WITH 8 CM DE DILATATION Y 100%,

SHE WANTS TO GET HYDROCHLORIDE (DON’T REMEMBER

THE EXACTLY NAME) FOR PAIN:

A- ADMINISTER EPIDURAL

B- ADMINISTER HYDROCHLORIDE

C- RELAXATION TECHNIQUE

53. Maternity – Postpartum – Hemorrhage postpartum

Possible asw: Check for clots and lochia

54. Maternity – Postpartum – Priority management-postpartum

After receiving shift report, the nurse working on a postpartum unit should

assessment first?

A) Vaginal birth today whose infant is refusing to breastfeed.

B) Cesarean birth of twin today who is new complaining of pain.

C) Post-cesarean birth today with fundus at the umbilicus.

D- Multipara vaginal birth yesterday saturating two pads hours.

55. Maternity/Medical Surgical – Antepartum – Barbiturates & pregnancy

The nurse is evaluating medication teaching. Which statement by a female who

takes a barbiturate for sleep indicates she understands the teaching?

a) “I should ensure that I do not become pregnant while taking this

medication.”

b) “I must take my birth control pill in the morning and my sleeping pill at

night.”

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c) “I will increase the amount I take in small doses if I can’t sleep through the

night.”

d) “I should take my anxiety pill, alprazolam, only when I really need it.”

56. Maternity/Medical Surgical –Postpartum –Post vaginal deliverydiaphragm

Patient that had a vaginal birth, diaphragm. What teaching the nurse need to give to

the patient?

A- 2 or 6 hours before intercourse

B- Re-adapt

C- Resisted diaphragm

D- Is no anticoncertive

57. Maternity/Professional Issues-Antepartum/Cultural/Spiritual-Pregnancycultural awareness

Pregnant women first prenatal visit at 12 weeks

A - Concern about delivery

B - Parenting

C - Complication during pregnancy

D - CHILDHOOD

58. Maternity/Professional Issues-Antepartum/Leadership-BPP-fetal wellbeing

Four clients arrive on the labor and delivery unit at the same time. Which client

should the nurse assess first?

a) A 41-week multigravida who is scheduled induction of labor today.

b) A 38-week primagravida who reports contractions occurring every 10 minutes.

c) A 36-week multigravida with a prescription for serial blood pressure.

d) A 39-week primigravida with biophysical profile score of 5 out of 8

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59. Medical Surgical-Cardiovascular-Angina-exercise

A male client with angina pectoris is being discharged from the hospital. What

instructions should the nurse plan to include to the discharge teaching?

a. Engage in physical exercise immediately after eating to help decrease

cholesterol levels.

b. Walk briskly in cold weather to increase cardiac output.

c. Keep nitroglycerin in a