Health Education Systems, Inc. (HESI) Registered Nurse (RN) Exit Exam FREE

The nurse is talking with a client. The client abruptly says to the nurse, “The moon is full. Astronauts walk on the moon. Walking is a good health habit.” The client’s behavior most likely indicates

A) Neologisms B) Dissociation C) Flight of ideas D) Word salad

C) Flight of ideas

A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize as normal at this age?

A) Jumping rope B) Tying shoelaces C) Riding a tricycle D) Playing hopscotch

C) Riding a tricycle

A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is

A) A transparent film dressing B) Wet dressing with debridement granules C) Wet to dry with hydrogen peroxide D) Moist saline dressing

D) Moist saline dressing

The nurse enters a 2 year-old child’s hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, “No!” What would be the most appropriate next action?

A) Leave the room and return five minutes later and give the medicine B) Explain to the child that the medicine must be taken now C) Give the medication to the father and ask him to give it D) Mix the medication with ice cream or applesauce

A) Leave the room and return five minutes later and give the medicine

A nurse is doing pre-conceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?

A) “I understand that a glass of wine with dinner is healthy. B) “Beer is not really hard alcohol, so I guess I can drink some. C) “If I drink, my baby may be harmed before I know I am pregnant. D) “Drinking with meals reduces the effects of alcohol.”

C) “If I drink, my baby may be harmed before I know I am pregnant.”

A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?

A) Increased blood pressure B) Increased heart rate C) Loss of pulse in the extremity D) Decreased urine output

C) Loss of pulse in the extremity

A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago.He received 1000 mL of IV fluid. Which action would be most likely to help him void?

A) Have him drink several glasses of water B) Crede’ the bladder from the bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again

C) Assist him to stand by the side of the bed to void

The nurse is caring for a client who requires a mechanical ventilator for breathing.The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

A) Disconnect the client from the ventilator and use a manual resuscitation bag B) Perform a quick assessment of the client’s condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator

B) Perform a quick assessment of the client’s condition

The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test?

A) “I can’t lie in 1 position for more than thirty minutes.” B) “I am allergic to shrimp.” C) “I suffer from claustrophobia.” D) “I developed a severe headache after a spinal tap.”

B) “I am allergic to shrimp.”

The health care provider order reads “aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate.” The pH of the aspirate is 10. Which action should the nurse take?

A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube

A) Hold the tube feeding and notify the provider

To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must

A) Apply suction for no more than 10 seconds B) Maintain sterile technique C) Lubricate 3 to 4 inches of the catheter tip D) Withdraw catheter in a circular motion

A) Apply suction for no more than 10 seconds

An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to

A) Administer the medication in 2 separate injections B) Give the medication in the dorsal gluteal site C) Call to get a smaller volume ordered D) Check with pharmacy for a liquid form of the medication

A) Administer the medication in 2 separate injections

The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to

A) Enhance absorption of the medication B) Ensure that the entire dose of medication is given C) Provide more even distribution of the drug D) Prevent the drug from tissue irritation

D) Prevent the drug from tissue irritation

A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?

A) Diaphoresis with decreased urinary output B) Increased heart rate with increase respirations C) Improved respiratory status and increased urinary output D) Decreased chest pain and decreased blood pressure

C) Improved respiratory status and increased urinary output

While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse’s best response?

A) “As you urinate more, you will need less medication to control fluid.” B) “You will have to take this medication for about a year.” C) “The medication must be continued so the fluid problem is controlled.” D) “Please talk to your health care provider about medications and treatments.”

C) “The medication must be continued so the fluid problem is controlled.”

A client is being discharged with a prescription for chlorpromazine (Thorazine).Before leaving for home, which of these findings should the nurse teach the client to report?

A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dyspnea, nasal congestion

B) Sore throat, fever

A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action should the nurse implement first?

A. Cleanse the foot with soap and water and apply an antibiotic ointment B. Provide teaching about the need for a tetanus booster within the next 72 hours. C. Have the mother check the child’s temperature q4h for the next 24 hours D. Transfer the child to the emergency department to receive a gamma globulin injection

A. Cleanse the foot with soap and water and apply an antibiotic ointment

A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences:

A. Bradycardia and constipation B. Lethargy and lack of appetite C. Muscle cramping and dry, flushed skin D. Palpitations and shortness of breath

D. Palpitations and shortness of breath

A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client?

Obtain a list of medications taken for cardiac history

Obtain a list of medications taken for cardiac history

The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply)

A. Fluid shifts from intravascular to interstitial area due to decreased serum protein
B. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
C. Increased circulating aldosterone levels that increase sodium and water retention

The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies)

Murmur

Murmur

A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?

A) Transparent dressing B) Dry sterile dressing with antibiotic ointment C) Wet to dry dressing D) Occlusive moist dressing

D) Occlusive moist dressing

A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child?

A) Cartoon stickers B) Large wooden puzzle C) Blunt scissors and paper D) Beach ball

B) Large wooden puzzle

A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the

A) Yang, the positive force that represents light, warmth, and fullness B) Yin, the negative force that represents darkness, cold, and emptiness C) Use of improper hot foods, herbs and plants D) A failure to keep life in balance with nature and others

B) Yin, the negative force that represents darkness, cold, and emptiness

A 2 year-old child has just been diagnosed with cystic fibrosis. The child’s father asks the nurse “What is our major concern now, and what will we have to deal with in the future?” Which of the following is the best response?

A) “There is a probability of life-long complications.” B) “Cystic fibrosis results in nutritional concerns that can be dealt with.” C) “Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis.” D) “You will work with a team of experts and also have access to a support group that the family can attend.”

C) “Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis.”

Which information is a priority for the RN to reinforce to an older client after intravenous pylegraphy?

A) Eat a light diet for the rest of the day
B) Rest for the next 24 hours since the preparation and the test is tiring.
C) During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days
D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

D: Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

Which type of accidental poisoning would the nurse expect to occur in children under age 6?

A) Oral ingestion B) Topical contact C) Inhalation D) Eye splashes

A) Oral ingestion

A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client?

A) Reading B) Checkers C) Cards D) Ping-pong

D) Ping-pong

The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?

A) Widening pulse pressure B) Pleural friction rub C) Distended neck veins D) Bradycardia

C) Distended neck veins

Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis?

A) Assess for generalized edema B) Monitor for increased urinary output C) Encourage rest during hyperactive periods D) Note patterns of increased blood pressure

D) Note patterns of increased blood pressure

The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the following actions by the nurse would be appropriate?

A) Schedule the therapy thirty minutes after meals B) Teach the child not to cough during the treatment C) Confine the percussion to the rib cage area D) Place the child in a prone position for the therapy

C) Confine the percussion to the rib cage area

Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?

A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs

A) Orthostatic hypotension is a common side effect

The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs?

A) Three apricots B) Medium banana C) Naval orange D) Baked potato

D) Baked potato

An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

A) Add a thickening agent to the fluids B) Check the client’s gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids

B) Check the client’s gag reflex

The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?

A) Place client in the wheelchair for four hours each day B) Pad the bony prominence C) Reposition every two hours D) Massage reddened bony prominence

C) Reposition every two hours

A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?

A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic client

A) A 79 year-old malnourished client on bed rest

Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse’s priority?

A) Obtain a complete blood count B) Obtain a health and dietary history C) Refer to a provider for a physical examination D) Measure height and weight

B) Obtain a health and dietary history

After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is

A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents

A) Abdominal x-ray

A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client?

A) Allow the client to melt ice chips in the mouth B) Provide mints to freshen the breath C) Perform frequent oral care with a tooth sponge D) Swab the mouth with glycerin swabs

C) Perform frequent oral care with a tooth sponge

The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

A) Exercise doing weight bearing activities B) Exercise to reduce weight C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones

A) Exercise doing weight bearing activities

The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?

A) Cheese sandwich with a glass of 2% milk B) Sliced turkey sandwich and canned pineapple C) Cheeseburger and baked potato D) Mushroom pizza and ice cream

B) Sliced turkey sandwich and canned pineapple

Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol?

A) All 4 side rails up, wheels locked, bed closest to door B) Lower side rails up, bed facing doorway C) Knees bent, head slightly elevated, bed in lowest position D) Bed in lowest position, wheels locked, place bed against wall

D) Bed in lowest position, wheels locked, place bed against wall

The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group?

A) Bulimia B) Anorexia C) Obesity D) Malnutrition

C) Obesity

At the geriatric day care program a client is crying and repeating “I want to go home. Call my daddy to come for me.” The nurse should

A) Invite the client to join the exercise group B) Tell the client you will call someone to come for her C) Give the client simple information about what she will be doing D) Firmly direct the client to her assigned group activity

C) Give the client simple information about what she will be doing

A victim of domestic violence states to the nurse, “If only I could change and be how my companion wants me to be, I know things would be different.” Which would be the best response by the nurse?

A) “The violence is temporarily caused by unusual circumstances, don’t stop hoping for a change. B) “Perhaps, if you understood the need to abuse, you could stop the violence. C) “No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?” D) “Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do.”

D) “Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do.”

A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is

A) difference in the intake and output
B) changes in the mucous membranes
C) skin turgor
D) weekly weight

D: weekly weight

A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn’t really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation?

A) Degeneration of the alveoli B) Chronic broncho constriction of the large airways C) Lung remodeling and permanent changes in lung function D) Frequent pneumonia

C) Lung remodeling and permanent changes in lung function

A mother wants to switch her 9 month-old infant from an iron fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?

A) Change the baby to whole milk B) Add chocolate syrup to the bottle C) Continue with the present formula D) Offer fruit juice frequently

C) Continue with the present formula

Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse make an exception to this practice?

A) When a family member offers information about their loved one B) When the client threatens self-harm and harm to others C) When the health care provider decides the family has a right to know the client’s diagnosis D) When a visitor insists that the visitor has been given permission by the client

B) When the client threatens self-harm and harm to others

The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care?

A) Monitor for hyperkalemia B) Place in protective isolation C) Precautions with position changes D) Administer diuretics as ordered

C) Precautions with position changes

The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment?

A) Activity intolerance caused by fatigue related to chronic tissue hypoxia B) Impaired mobility related to chronic obstructive pulmonary disease C) Self-care deficit caused by fatigue related to dyspnea D) Ineffective airway clearance related to increased bronchial secretions

A) Activity intolerance caused by fatigue related to chronic tissue hypoxia

A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most important for the nurse to reinforce with the client?

A) It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum)
B) It is critical to report promptly to your health care provider any findings of peptic ulcers
c) Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors
D) With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine

The correct answer is B: It is critical to report promptly to your health care provider any findings of peptic ulcers.

The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?

A) Standing and sitting B) In both arms C) After exercising D) Supine position

B) In both arms

The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group?

A) Aerobic exercise classes B) Transportation for shopping trips C) Reminiscence groups D) Regularly scheduled social activities

C) Reminiscence groups

Post-procedure nursing interventions for electroconvulsive therapy include

A) Applying hard restraints if seizure occurs B) Expecting client to sleep for 4 to 6 hours C) Remaining with client until oriented D) Expecting long-term memory loss

C) Remaining with client until oriented

The nurse assesses delayed gross motor development in a 3 year-old child. The inability of the child to do which action confirms this finding?

A) Stand on 1 foot B) Catch a ball C) Skip on alternate feet D) Ride a bicycle

A) Stand on 1 foot

The mother of a 15 month-old child asks the nurse to explain her child’s lab results and how they show her child has iron deficiency anemia. The nurse’s best response is

A) “Although the results are here, your doctor will explain them later. B) “Your child has less red blood cells that carry oxygen. C) “The blood cells that carry nutrients to the cells are too large.” D) “There are not enough blood cells in your child’s circulation.”

B) “Your child has less red blood cells that carry oxygen.”

In a child with suspected coarctation of the aorta, the nurse would expect to find

A) Strong pedal pulses B) Diminishing carotid pulses C) Normal femoral pulses D) Bounding pulses in the arms

D) Bounding pulses in the arms

At the day treatment center a client diagnosed with Schizophrenia – Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client’s behavior most likely indicates

A) Feelings of increasing anxiety related to paranoia B) Social isolation related to altered thought processes C) Sensory perceptual alteration related to withdrawal from environment D) Impaired verbal communication related to impaired judgment

B) Social isolation related to altered thought processes

A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client’s blood pressure is increasing. Which action should the nurse take first?

A) Check the protein level in urine
B) Have the client turn to the left side
C) Take the temperature
D) Monitor the urine output

B: Have the client turn to the left side

A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0- to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to

A) Ask the client about the refusal of certain pain medications B) Talk with the client’s family about the situation C) Report the situation to the health care provider D) Document the situation in the notes

A) Ask the client about the refusal of certain pain medications

What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

A) Presence of blood in stools
B) Oozing liquid stool
C) Continuous rumbling flatulence
D) Absence of bowel movements

B) Oozing liquid stool

A client in a long term care facility complains of pain. The nurse collects data about the client’s pain. The first step in pain assessment is for the nurse to

A) Have the client identify coping methods B) Get the description of the location and intensity of the pain C) Accept the client’s report of pain D) Determine the client’s status of pain

C) Accept the client’s report of pain

An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be

A) Assess the severity and location of the pain B) Obtain an order for an analgesic C) Reassure him that this is not unusual for his age D) Encourage him to increase his activity

A) Assess the severity and location of the pain

A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that

A) Visitors must wear a mask and a gown B) There are no special requirements for visitors of clients on contact precautions C) Visitors should wash their hands before and after touching the client D) Visitors

C) Visitors should wash their hands before and after touching the client

A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?

A) Institute seizure precautions B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h

C) Place in respiratory/secretion precautions

Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia

D) Altered patterns of urinary elimination related to nocturia

A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these?

A) Apply appropriate signs outside and inside the room B) Apply a mask with a shield if there is a risk of fluid splash C) Wear a gown to change soiled linens from incontinence D) Have gloves on while handling bedpans with feces

D) Have gloves on while handling bedpans with feces

Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours?

A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin

B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear

A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client?

A) Reverse B) Airborne C) Standard precautions D) Contact

D) Contact

The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements?

A) “The treatment requires reapplication in 8 to 10 days.” B) “Bedding and clothing can be boiled or steamed.” C) Children are not to share hats, scarves and combs. D) Nit combs are necessary to comb out nits.

C) Children are not to share hats, scarves and combs.

During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches?

A) Wash hands thoroughly before and after client contact B) Wear gloves when in contact with body secretions C) Double glove when in contact with feces or vomitus D) Wear gloves when disposing of contaminated linens

A) Wash hands thoroughly before and after client contact

A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes?

A) Grilled chicken sandwich and skim milk B) Roast beef, mashed potatoes, and green beans C) Peanut butter sandwich, banana, and iced tea D) Barbecue beef, baked beans, and cole slaw

B) Roast beef, mashed potatoes, and green beans

After talking with her partner, a client voluntarily admitted herself to the substance abuse unit. After the second day on the unit the client states to the nurse, “My husband told me to get treatment or he would divorce me. I don’t believe I really need treatment but I don’t want my husband to leave me.” Which response by the nurse would assist the client?

A) “In early recovery, it’s quite common to have mixed feelings, but unmotivated people can’t get well.” B) “In early recovery, it’s quite common to have mixed feelings, but I didn’t know you had been pressured to come.” C) “In early recovery it’s quite common to have mixed feelings, perhaps it would be best to seek treatment on an out client bases. ” D) ” In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of sobriety for you.”

D) ” In early recovery, it’s quite common to have mixed feelings. Let’s discuss the benefits of sobriety for you.”

A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passes loose, watery stool. Which of these is a nursing priority?

A) Hold the infant at frequent intervals. B) Assess for neonatal withdrawal syndrome C) Offer fluids to prevent dehydration D) Administer paregoric to stop diarrhea

B) Assess for neonatal withdrawal syndrome

The nurse is caring for a post myocardial infarction client in an intensive care unit. It is noted that urinary output has dropped from 60 -70 ml per hour to 30 ml per hour. This change is most likely due to

A) Dehydration B) Diminished blood volume C) Decreased cardiac output D) Renal failure

C) Decreased cardiac output

The primary nursing diagnosis for a client with congestive heart failure with pulmonary edema is

A) Pain B) Impaired gas exchange C) Cardiac output altered: decreased D) Fluid volume excess

C) Cardiac output altered: decreased

The nurse is performing a developmental assessment on an 8 month-old. Which finding should be reported to the health care provider?

A) Lifts head from the prone position B) Rolls from abdomen to back C) Responds to parents’ voices D) Falls forward when sitting

D) Falls forward when sitting

A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other measure should the nurse implement?

A) Have respiratory support equipment available B) Immediately place her in the seclusion room C) Assess the client for anxiety and agitation D) Administer PRN dose of IM antipsychotic medication

A) Have respiratory support equipment available

The nurse walks into a client’s room and finds the client lying still and silent on the floor. The nurse should first

A) Assess the client’s airway B) Call for help C) Establish that the client is unresponsive D) See if anyone saw the client fall

C) Establish that the client is unresponsive

The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to

A) Check for subcutaneous emphysema in the upper torso B) Reposition the client to a position of comfort C) Call the health care provider as soon as possible D) Check for any increase in the amount of thoracic drainage

A) Check for subcutaneous emphysema in the upper torso

The nurse is teaching a client with dysrhythmia about the electrical pathway of an impulse as it travels through the heart. Which of these demonstrates the normal pathway?

A) AV node, SA node, Bundle of His, Purkinje fibers B) Purkinje fibers, SA node, AV node, Bundle of His C) Bundle of His, Purkinje fibers, SA node , AV node D) SA node, AV node, Bundle of His, Purkinje fibers

D) SA node, AV node, Bundle of His, Purkinje fibers

When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first?

A) Try to vigorously stimulate normal breathing B) Ask the RN to assess the vital signs C) Measure the pulse oximetry D) Continue to monitor respirations

D) Continue to monitor respirations

When assessing a client, it is important for the nurse to be informed about cultural issues related to the client’s background because

A) Normal patterns of behavior may be labeled as deviant, immoral, or insane B) The meaning of the client’s behavior can be derived from conventional wisdom C) Personal values will guide the interaction between persons from 2 cultures D) The nurse should rely on her knowledge of different developmental mental stages

A) Normal patterns of behavior may be labeled as deviant, immoral, or insane

The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?

A) Assign an RN to provide total care of the client B) Assign a nursing assistant to help the client with self-care activities C) Delegate complete care to an unlicensed assistive personnel D) Supervise a nursing assistant for skin care

D) Supervise a nursing assistant for skin care

The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process?

A) Assist a client post cerebral vascular accident to ambulate B) Feed a 2 year-old in balanced skeletal traction C) Care for a client with discharge orders D) Collect a sputum specimen for acid fast bacillus

C) Care for a client with discharge orders

After working with a very demanding client, an unlicensed assistive personnel(UAP) tells the nurse, “I have had it with that client. I just can’t do anything that pleases him. I’m not going in there again.” The nurse should respond by saying

A) “He has a lot of problems. You need to have patience with him. “B) “I will talk with him and try to figure out what to do.” C) “He is scared and taking it out on you. Let’s talk to figure out what to do.” D) “Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day.”

C) “He is scared and taking it out on you. Let’s talk to figure out what to do.”

A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client’s mental status and adjustment. The appropriate response of the nurse should be which of these statements?

A) I am sorry. Referral information can only be provided by the client’s health care providers. B) “I can never give any information out by telephone. How do I know who you are?” C) Since this is a referral, I can give you this information. D) I need to get the client’s written consent before I release any information to you.

D) I need to get the client’s written consent before I release any information to you.

A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states “I don’t think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.” The nurse should understand that

A) A referral is needed to the psychiatrist who is to provide the client with answers B) The client has a right to know about the prescribed medications C) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications D) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects

B) The client has a right to know about the prescribed medications

The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?

A) Diminished bowel sounds
B) Loss of appetite
C) A cold, pale lower leg
D) Tachypnea

C: A cold, pale lower leg

Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?

A) “Have the client sit on the side of the bed for at least 2 minutes before helping him stand.” B) “If the client is dizzy on standing, ask him to take some deep breaths.” C) “Assist the client to the bathroom at least twice on this shift.” D) “After you assist him to the chair, let me know how he feels.”

A) “Have the client sit on the side of the bed for at least 2 minutes before helping him stand.”

The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider?

A) Nausea and vomiting
B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)
C) Diffuse macular rash
D) Muscle tenderness

B: Fever of 103 degrees F (39.5 degrees C)

The nurse receives a report on an older adult client with middle stage dementia.What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client

A) Has had a change in respiratory rate by an increase of 2 breaths B) Has had a change in heart rate by an increase of 10 beats C) Was minimally responsive to voice and touch D) Has had a blood pressure change by a drop in 8 mmHg systolic

C) Was minimally responsive to voice and touch

The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include

A) Pointing out inconsistencies in speech patterns to correct thought disorders
B) Accepting client and the client’s behavior unconditionally
C) Encouraging dependency in order to develop ego controls
D) Consistent limit-setting enforced 24 hours per day

D) Consistent limit-setting enforced 24 hours per day

A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

A) Until the health care provider has determined that your ejaculate doesn’t contain sperm, continue to use another form of contraception.
B) This procedure doesn’t impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate.
C) After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn’t involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
D) The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the- counter pain medication to relieve any discomfort.

A: Until the health care provider has determined that your ejaculate doesn’t contain sperm, continue to use another form of contraception.

Following a cocaine high, the user commonly experiences an extremely unpleasant feeling called

A) Craving B) Crashing C) Outward bound D) Nodding out

B) Crashing

The nurse asks a client with a history of alcoholism about the client’s drinking behavior. The client states “I didn’t hurt anyone. I just like to have a good time, and drinking helps me to relax.” The client is using which defense mechanism?

A) Denial B) Projection C) Intellectualization D) Rationalization

D) Rationalization

One reason that domestic violence remains extensively undetected is

A) Few battered victims seek medical care B) There is typically a series of minor, vague complaints C) Expenses due to police and court costs are prohibitive D) Very little knowledge is currently known about batterers and battering relationships

B) There is typically a series of minor, vague complaints

A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?

A) S3 heart sound B) Thready pulse C) Flattened neck veins D) Hypoventilation

A) S3 heart sound

An explosion has occurred at a high school for children with special needs and severe developmental delays. One of the students accompanied with a parent is seen at a community health center a day later. After the initial assessment the nurse concludes that the student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next?

A) Help the student to identify a specific problem B) Ask the parent to identify the major problem C) Ask the student to think of different alternatives D) Examine with the parent a variety of options

B) Ask the parent to identify the major problem

Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode?

A) “I think all children should have their heads shaved. B) “I have been restricted in thought and harmed.” C) “I have powers to get you whatever you wish, no matter the cost. “D) “I think all of my contacts last week have attempted to poison me.”

C) “I have powers to get you whatever you wish, no matter the cost.”

A client says, “It’s raining outside and it’s raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I’ve never been to Ireland.” The nurse would document this behavior as

A) Perseveration B) Circumstantiality C) Neologisms D) Flight of ideas

D) Flight of ideas

During the change-of-shift report the assigned nurse notes a Catholic client is scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of prejudice?

A) “I wonder who is paying for this trip to the hospital? B) “I think she needs to go to the city hospital. C) “All those people indulge in large families! D) “Doesn’t she know there’s such a thing as birth control?”

D) “Doesn’t she know there’s such a thing as birth control?”

Which of these statements by the nurse reflects the best use of therapeutic interaction techniques?

A) “You look upset. Would you like to talk about it? B) “I’d like to know more about your family. Tell me about them.” C) “I understand that you lost your partner. I don’t think I could go on if that happened to me.” D) “You look very sad. How long have you been this way?”

A) “You look upset. Would you like to talk about it?”

A nurse in the emergency department suspects domestic violence as the cause of a client’s injuries. What action should the nurse take first?

A) Ask client if there are any old injuries also present B) Interview the client without the persons who came with the client C) Gain client’s trust by not being hurried during the intake process D) Photograph the specific injuries in question

B) Interview the client without the persons who came with the client

The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding?

A) Decreased urinary output
B) Jugular vein distention
C) Pleural effusion
D) Bibasilar crackles

B: Jugular vein distention

A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication

A) Can predispose to dysrhythmias
B) May lead to oliguria
C) May cause irritability and anxiety
D) Sometimes alters consciousness

A: Can predispose to dysrhythmias

A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?

A) Flaccid paralysis
B) Pupils fixed and dilated
C) Diminished spinal reflexes
D) Reduced sensory responses

B: Pupils fixed and dilated

A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture?

A) Some needles go as deep as 3 inches, depending on where they’re placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes.
B) In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness.
C) The flow of life is believed to flow through major pathways or nerve clusters in your body.
D) By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is believed that energy flow will rebalance to allow the body’s natural healing mechanisms to take over.

C) The flow of life is believed to flow through major pathways or nerve clusters in your body.

The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?

A) It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes. B) In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain C) Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent D) Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to2 weeks

C) Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent

A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission?

A) Side-lying on the left with the head elevated 10 degrees B) Side-lying on the left with the head elevated 35 degrees C) Side-lying on the right wil the head elevated 10 degrees D) Side-lying on the right with the head elevated 35 degrees

A) Side-lying on the left with the head elevated 10 degrees

A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider?

A) Light, pink urine B) Occasional suprapubic cramping C) Minimal drainage into the urinary collection bag D) Complaints of the feeling of pulling on the urinary catheter

C) Minimal drainage into the urinary collection bag

A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse?

A) Relieve the nurse performing CPR B) Go get the code cart C) Participate with the compressions or breathing D) Validate the client’s advanced directive

C) Participate with the compressions or breathing

A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis?

A: “I knew this would happen. I’ve been eating too much red meat lately.” B: “I really enjoyed my fishing trip yesterday. I caught 2 fish.” C: “I have really been working hard practicing with the debate team at school.” D: “I went to the health care provider last week for a cold and I have gotten worse.”

D: “I went to the doctor last week for a cold and I have gotten worse.”

Which these findings would the nurse more closely associate with anemia in a 10 month-old infant?

A) Hemoglobin level of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A heart rate between 140 to 160

B: Pale mucosa of the eyelids and lips

The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is

A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses

D: Pupil responses

Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump?

A) A young adult with a history of Down’s syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness

D: A preschooler with intermittent episodes of alertness

The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be

A) Irritable and “colicky” with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C)Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings

D: Pale, thin arms and legs, uninterested in surroundings

As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion?

A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss

D: Hair loss

While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today’s temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to

A) Call the health care provider immediately B) Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client’s fluid intake

B: Administer acetaminophen as ordered as this is normal at this time

A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse’s priority should be

A) Cover the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Initiate intravenous therapy D) Administer pain medication

B: Assess for dyspnea or stridor

Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider?

A) I started my period and now my urine has turned bright red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn’t hurt when I went.

D: I went to the bathroom and my urine looked very red and it didn’t hurt when I went.

A middle aged woman talks to the nurse in the health care provider’s office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed?

A) I am one out of every 4 women that get fibroids, and of women my age – between the 30s or 40s, fibroids occurs more frequently. B) My fibroids are noncancerous tumors that grow slowly. C) My associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention and constipation. D) Fibroids that cause no problems still need to be taken out.

D: Fibroids that cause no problems still need to be taken out.

An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next?

A) Stay with client and observe for airway obstruction B) Collect pillows and pad the side rails of the bed C) Place an oral airway in the mouth and suction D) Announce a cardiac arrest, and assist with intubation

A: Stay with client and observe for airway obstruction

A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor?

A) FHT 168 beats/min B) Temperature 100 degrees Fahrenheit. C) Cervical dilation of 4 D) BP 138/88

A: FHT 168 beats/min

A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse’s initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication?

A) “I have a sharp pain in my chest when I take a breath.” B) “I have been coughing up foul-tasting, brown, thick sputum.” C) “I have been sweating all day.” D) “I feel hot off and on.”

B: “I have been coughing up foul tasting, brown, thick sputum.”

The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal

A) S3 ventricular gallop B) Apical click C) Systolic murmur D) Split S2

A: S3 ventricular gallop

Which of these observations made by the nurse during an excretory urogram indicate a complication?

A) The client complains of a salty taste in the mouth when the dye is injected B) The client’s entire body turns a bright red color C) The client states “I have a feeling of getting warm.” D) The client gags and complains ” I am getting sick.”

B: The client’s entire body turns a bright red color

A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?

A) “The tube will drain fluid from your chest.” B) “The tube will remove excess air from your chest.” C) “The tube controls the amount of air that enters your chest.” D) “The tube will seal the hole in your lung.”

B: “The tube will remove excess air from your chest.”

The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?

A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7.30 D) Serum potassium 6 mEq/L

D: Serum potassium 6 mEq/L

The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse’s immediate attention?

A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms

C: Dyspnea

The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse?

A) Breath sounds can be heard bilaterally B) Mist is visible in the T-Piece C) Pulse oximetry of 88 D) Client is unable to speak

C: Pulse oximetry of 88

A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?

A) drowsiness B) complaint of nausea C) pulse rate of 92 D) restlessness

D: restlessness

The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to

A) Maintain adequate hydration B) Assist client to turn, deep breathe, and cough C) Ambulate client within 12 hours D) Splint incision

B: Assist client to turn, deep breathe, and cough

When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote

A) Relaxation and sleep B) Deep breathing and coughing C) Incisional healing D) Range of motion exercises

B: Deep breathing and coughing

A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?

A) Ask client to cough sputum into container B) Have the client take several deep breaths C) Provide a appropriate specimen container D) Assist with oral hygiene

D: Assist with oral hygiene

The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?

A) Blanch nail beds for color and refill B) Assess for post operative arrhythmias C) Auscultate for pulmonary congestion D) Monitor equality of peripheral pulses

B: Assess for post operative arrhythmias

A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client’s room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first?

A) Obtain a 12-lead EKG B) Place client in high Fowler’s position C) Lower the oxygen rate D) Take baseline vital signs

C: Lower the oxygen rate

A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?

A) Notify the health care provider B) Readjust the traction C) Administer the ordered prn medication D) Reassess the foot in fifteen minutes

A: Notify the health care provider

The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse’s first action should be to

A) Wrap the leg with elastic bandages B) Apply pressure at the bleeding site C) Reinforce the dressing and elevate the leg D) Remove the dressings and re-dress the incision

C: Reinforce the dressing and elevate the leg

A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care?

A) Esophagitis B) Leukopenia C) Fatigue D) Skin irritation

B: Leukopenia

A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?