HESI Comprehensive Exit Exam Answered A+ Solution Guide. 1-Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administ... ering the medication? A. Checking the client's blood pressure B. Checking the client's peripheral pulses C. Checking the most recent potassium level D. Checking the client's intake-and-output record for the last 24 hours Correct 2-A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? A. "The test will take about 30 minutes." B. "I need to fast for 8 hours before the test." C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." D. "I need to take a laxative after the test is completed, because the liquid that I'll have to drink for the test can be constipating." 3-A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should: A. Call the nursing supervisor B. Ask the answering service to contact the on-call physician C. Withhold the medication until the physician can be reached in the morning D. Administer the medication but consult the physician when he becomes available 4.An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is: A. Documenting the findings B. Asking the ED physician to check the client C. Continuing to monitor the client's cardiac status D. Informing the client that PVCs are expected after an MI A. Administer the antihypertensive with a small sip of water B. Withhold the antihypertensive and administer it at bedtime C. Administer the medication by way of the intravenous (IV) route D. Hold the antihypertensive and resume its administration on the day after the ECT 6 A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? A. "Tell me more about what you're feeling." B. "That's a normal response after this type of surgery." C. "It will take time, but, I promise you, you will get over this depression." D. "Every client who has this surgery feels the same way for about a month." 7 A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse's priority? A. Contacting the physician B. Documenting the findings C. Checking the fluid for protein D. Continuing to monitor the client and the FHR 8 A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to: A. Call the radiography department to obtain a chest x-ray B. Check the client's blood glucose level to serve as a baseline measurement C. Hang the prescribed bag of PN and start the infusion at the prescribed rate D. Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency 9 A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the appropriate response by the nurse? A. "HIV is rarely an issue in rape victims." B. "Every rape victim is concerned about HIV." C. "You're more likely to get pregnant than to contract HIV." D. "Let's talk about the information that you need to determine your risk of contracting HIV." 10 A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to: A. Contact the physician B. Stop taking the medication C. Take the medication with food D. Take the medication twice a day instead of four times 11 A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour period? Type your answer in the space provided. Answer: ________mL 12 Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of: A. 3 minutes B. 10 seconds C. 15 seconds D. 30 minutes 13 A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of: A. Depression B. Diabetes mellitus C. Hyperthyroidism D. Coronary artery disease 14 Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences: A. Dry mouth B. Restlessness C. Feelings of depression D. Neck stiffness or soreness 15 Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing physician before administering the medication? A. The client has a history of cataracts. B. The client has a history of hypothyroidism. C. The client takes a prescribed antihypertensive. D. The client is allergic to acetylsalicylic acid (aspirin). 16 A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which of the following findings does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client? A. Fever B. Diarrhea C. Hypertension D. Tongue protrusion 17 A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client's record, would indicate a need to contact the physician who is scheduled to perform the ECT? A. Recent stroke B. Hypothyroidism C. History of glaucoma D. Peripheral vascular disease 18 A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through: A. A lower abdominal incision B. An upper abdominal incision C. An incision made in the perineal area D. The urethra, with the use of a cutting wire 19 A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply. A. Seek medical advice if you find a skin lesion. B. Use sunscreen with a low sun protection factor (SPF). C. Avoid sun exposure before 10 a.m. and after 4 p.m. D. Wear a hat, opaque clothing, and sunglasses when out in the sun. E. Examine the body every 6 months for possibly cancerous or precancerous lesions. 20 A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast? SEE PICS A. B. C. D. 21 The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother: A. To always administer less insulin on the days of soccer games B. That it is best not to encourage the child to participate in sports activities C. That the child should eat a carbohydrate snack about a half-hour before each soccer game D. To administer additional insulin before a soccer game if the blood glucose level is 240 mg/dL or higher and ketones are present 22 A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? A. Anxiety B. Powerlessness C. Ineffective coping D. Disturbed body image 23 A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic? A. "What are your feelings right now?" B. "Why don't you feel like washing up?" C. "You aren't talking today. Cat got your tongue?" D. "You need to get yourself cleaned up. You have company coming today." 24 Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the physician with the procedure, expect to note? A. Clear and yellow B. Thick and opaque C. White and odorless D. Clear, with a foul odor 25 An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client? A. Administering 100% oxygen B. Having a crisis counselor available C. Instituting suicide precautions for the client D. Obtaining blood for determination of the client's carboxyhemoglobin level 26 A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify? A. Anxiety B. Powerlessness C. Disruption of thought processes D. Inability to maintain health 27 A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder? A. "Do you chew tobacco?" B. "Do you smoke cigarettes?" C. "Have you ever worked in a mine?" D. "Are you frequently exposed to paint products?" 28 A physician prescribes a dose of morphine sulfate 2.5 mg stat to be administered intravenously to a client in pain. The nurse preparing the medication notes that the label on the vial of morphine sulfate solution for injection reads "4 mg/mL." How many milliliters (mL) must the nurse draw into a syringe for administration to the client? Type the answer in the space provided. Answer: _____mL 29 A client undergoing therapy with carbidopa/levodopa (Sinemet) calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. The nurse should tell the client: A. To call his physician B. That he needs to drink more fluids C. That this is an occasional side effect of the medication D. That this may be a sign of developing toxicity of the medication 30 A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting: A. Bradycardia B. Increased heart rate C. Decreased blood pressure D. Improved swallowing function 31 A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication? A. Insomnia B. Rigidity and akinesia C. Bilateral lung wheezes D. Orthostatic hypotension 32 A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet?Select all that apply. A. Smoking Correct B. A high-calcium diet C. High alcohol intake Correct D. White or Asian ethnicity Correct E. Participation in physical activities that promote flexibility and muscle strength 33 A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is: A. Corn B. Cocoa C. Peaches D. Sardines 34 A nurse is providing information to a client with acute gout about home care. Which of the following measures does the nurse tell the client to take? Select all that apply. A. Drinking 2 to 3 L of fluid each day B. Applying heat packs to the affected joint C. Resting and immobilizing the affected area D. Consuming foods high in purines E. Performing range-of-motion exercise to the affected joint three times a day 35 A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. A. Fatigue B. Anemia C. Weight loss D. Low-grade fever E. Joint deformities 36 A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply. A. Fever B. Vasculitis C. Weight gain D. Increased energy E. Abdominal pain 37 A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply. A. Beer B. Apples C. Yogurt D. Baked haddock E. Pickled herring F. Roasted fresh potatoes 38 The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should: A. Contact the physician B. Hold the next dose of imipramine C. Document the laboratory result in the client's record D. Have another blood sample drawn and ask the laboratory to recheck the imipramine level 39 A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. A. "I need to avoid salt in my diet." B. "It's fine to take any over-the-counter medication with the lithium." C. "I need to come back the clinic to have my lithium blood level checked." D. " I should drink 2 to 3 quarts of liquid every day." E. "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned." 40 A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should: A. Contact the physician B. Document the findings C. Institute seizure precautions D. Have a blood specimen drawn immediately for serum lithium testing 41 A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves: A. Having the client perform a healthy coping behavior B. Having the client perform a ritualistic or compulsive behavior C. Providing a high degree of exposure of the client to the stimulus that the client finds undesirable D. Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening 42 A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really thirsty — may I have something to drink?" Before giving the client a drink, the nurse should: A. Check the client's vital signs B. Check for the presence of a gag reflex C. Assess the client for the presence of bowel sounds D. Ask the client to gargle with a warm saline solution 43 A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority? A. Inability to cope B. Decreased nutrition C. Decreased fluid volume D. Inability to tolerate activity 44 A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine: A. The sex of the fetus B. Genetic characteristics C. An accurate age for the fetus D. The degree of fetal lung maturity 45 A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply. A. Bananas B. Potatoes C. Spinach D. Legumes E. Whole grains F. Milk products 46 A nurse caring for a client with pre-eclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside? A. Vitamin K B. Protamine sulfate C. Potassium chloride D. Calcium gluconate 47 A nurse is monitoring a client receiving terbutaline (Brethine) by intravenous infusion to stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by the nurse is: A. Contacting the physician B. Documenting the findings C. Continuing to monitor the client D. Increasing the rate of the infusion 48 A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that: A. Sodium intake is restricted B. Fluid intake must be limited to 1 quart each day C. Urine output must be measured and that the physician should be notified if output is less than 500 mL in a 24-hour period D. Urinary protein must be measured and that the physician should be notified if the results indicate a trace amount of protein 49 A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which items of the following information elicited during the assessment indicate that the condition has not yet resolved? Type the option number that is the correct answer. 50 A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client? A. Spontaneous bruising B. Decrease in uterine size C. Urine output of 30 mL/hr D. Brownish vaginal discharge 51 A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately: A. Stops the oxytocin infusion Correct B. Checks the vagina for crowning C. Encourages the client to take short, deep breaths D. Increases the rate of the oxytocin infusion and calls the physician 52 A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which of the following actions should the nurse take as a result of this observation? A. Repositioning the mother B. Documenting the finding Correct C. Notifying the nurse-midwife D. Taking the mother's vital signs 53 A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client? A. Nausea B. Bloody urine C. Hearing loss D. Electrocardiographic changes 54 A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of the client? A. Painful vaginal bleeding B. Sustained tetanic contractions C. Complaints of abdominal pain D. Soft, relaxed, nontender uterus 55 A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which of the following observations indicates to the nurse that placental separation has occurred? A. A discoid uterus B. Sudden sharp vaginal pain C. Shortening of the umbilical cord D. A sudden gush of dark blood from the introitus 56 A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which of the following findings would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy? A. The client reports a history of sexual abuse by her father. B. The client reports that her relationship with her spouse is stable. C. The client reports a satisfying intimate relationship with her spouse. D. The client reports that her and her spouse have never been able to conceive children 57 A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction? A. "I can resume sexual activity in 4 to 6 weeks." B. "I need to avoid straining when I have a bowel movement." C. "I should wear support hose for 6 months and elevate my legs frequently." D. "I need to contact my surgeon immediately if I feel any numbness in my genital area." 58 An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply. A. Skin tenting B. Flat neck veins C. Weak peripheral pulses D. Moist oral mucous membranes E. A heart rate of 88 beats/min F. A respiratory rate of 18 breaths/min 59 An adult client with renal failure who is oliguric and undergoing hemodialysis is under a fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have between 7 a.m. and 3 p.m.?Type your answer in the space provided. Answer ____mL 60 A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use: A. Salt substitutes B. Herbs and spices C. Salt with cooking only D. Processed foods as desired 61 A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse that the client understands the instructions? A. Coffee B. Broccoli C. Cheeseburger D. Chocolate milk 62 Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client? A. Headache B. Drowsiness C. Photophobia D. Urinary frequency 63 A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client? A. Diarrhea B. Vomiting C. Epistaxis D. Epigastric pain 64 A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk? A. Count the number of times that the infant swallows during a feeding B. Weigh the infant every day and check for a daily weight gain of 2 oz C. Count wet diapers to be sure that the infant is having at least six to 10 each day D. Pump the breasts, place the milk in a bottle, measure the amount, and then bottle-feed the infant 65 A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information? A. "My child will need to do exercises." B. "My child needs to wear the brace 18 to 23 hours per day." C. "Wearing the brace is really important in curing the scoliosis." D. "I need to check my child's skin under the brace to be sure it doesn't break down." 66 Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with: A. Milk B. Water C. Any meal D. Tomato juice 67 A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally: A. Increase B. Decrease C. Remain unchanged D. Double from what they normally are 68 A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that: A. No edema is present B. The client is dehydrated C. Pitting edema is present D. Blood is not pooling in the extremities 69 A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would: A. Contact the physician B. Document the findings C. Ask the client to walk for 5 minutes, then recheck the reflexes D. Perform active and passive range-of-motion exercises of the client's lower extremities, then recheck the reflexes 70 After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client? A. Hysterectomy B. Insertion of an indwelling catheter C. Administration of oxytocin (Pitocin) D. Replacement of the uterus through the vagina into a normal position 71 A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would: A. Notify the physician B. Recheck the temperature in 4 hours C. Encourage the client to breastfeed the newborn D. Institute strict bedrest for the client and notify the physician 72 -A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial action should be: A. Documenting the findings B. Encouraging the woman to walk C. Helping the woman empty her bladder Correct D. Massaging the fundus gently until it becomes firm 73-A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time? A. Anxiety Correct B. Premature grief C. Fluid volume loss D. Fluid volume overload 74 -A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client? A. Increased platelet count B. Shortened prothrombin time C. Positive result on d-dimer study D. Decreased fibrin-degradation products 75 -A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply. A. Tachycardia Correct B. Cool, clammy skin C. Decreased respiratory rate D. Diminished peripheral pulses Correct E. Urine output of less than 30 mL/hr 76- A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock? A. Checking the client's urine output B. Inserting an intravenous (IV) line C. Obtaining informed consent for a cesarean delivery D. Placing the client in a lateral position with the bed flat 77 -A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician? A. Pink lochia on postpartum day 4 B. White lochia on postpartum day 11 C. Bloody lochia on postpartum day 2 D. Reddish lochia on postpartum day 8 78 A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to: A. Document the findings B. Ask the physician to see the client immediately C. Ask another nurse to check for the uterine fundus D. Place the client in the supine position for 5 minutes, then recheck the abdome 79- A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta? A. "Many of my antibodies are passed through the placenta." B. "The placenta maintains the body temperature of my baby." C. "Glucose, vitamins, and electrolytes pass through the placenta." D. "It provides an exchange of oxygen and carbon dioxide between me and my baby." 80 -A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is: A. June 2, 2013 B. July 2, 2013 C. October 2, 2013 D. September 18, 2013 81 A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication? A. Steak B. Spinach C. Chicken D. Oranges 82 -A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy? A. Sodium 140 mEq/L B. Hemoglobin 12.5 g/dL C. Blood urea nitrogen (BUN) 20 mg/dL D. White blood cell count of 2500 cells/mm3 83 -Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse? A. Nulliparity B. Early menarche C. Multiple sexual partners Correct D. Hormone-replacement therapy 84 -A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding? A. Umbilical cord compression B. Pressure on the fetal head during a contraction C. Uteroplacental insufficiency during a contraction Correct D. Inadequate pacemaker activity of the fetal heart 85- A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed: A. At any time after the surgery B. When menstruation resumes C. When pelvic sensation and response to stimuli return D. In about 6 weeks, when the vaginal vault is satisfactorily healed 86 -A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery is: A. Monitoring the client for signs of returning peristalsis B. Instructing the client in dietary changes to prevent constipation C. Encouraging the client to deep-breathe, cough, and use an incentive spirometer Correct D. Encouraging the client to talk about the effects of the surgery on her femininity and sexual 87- A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the medication, does the nurse monitor the client? A. Fever B. Dizziness C. Flatulence D. Drowsiness 88 -A nurse is providing instructions to a client with glaucoma who will be using acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client to report to the physician? A. Nausea B. Dark urine C. Urinary frequency D. Decreased appetite 89 -A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement? A. Frequent suctioning B. Maintaining cuff pressure C. Maintaining mechanical ventilation settings D. Alternating the use of a cuffed tube with a cuffless tube on a daily basis 90 - A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube? SEE PIC A. B. C. D. C 91 -Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply A. Keeping the room slightly darkened B. Placing the client in a room with a quiet roommate C. Encouraging isometric exercises if bed rest is prescribed D. Monitoring the client for changes in alertness or mental status E. Restricting visits to close family members and significant others and keeping visits short 92 -A nurse, providing information to a client who has just been found to have diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply. A. Hunger B. Weakness C. Blurred vision D. Increased thirst E. Increased urine output 93- A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the physician's instructions, understanding that the gait was selected after assessment of the client's: A. Physical and functional abilities B. Feelings about restricted mobility C. Uneasiness about using the crutches D. Understanding of the need for increased mobility 94- A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral tube feedings that will be continued after he is discharged home. When the nurse tells the client that he will be taught how to administer the feedings, the client states, "I don't think I'll be able to do these feedings by myself." Which response by the nurse is appropriate? A. "Have you told your doctor how you feel?" B. "Tell me more about your concerns regarding the tube feedings." C. "Don't worry. We'll keep you in the hospital until you're ready to do them by yourself." D. "We'll ask the doctor about having a visiting nurse come to your home to give you your feedings." 95- A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis of the ABG result, the nurse prepares to: A. Continue monitoring the client B. Increase the amount of humidified oxygen C. Continue administering humidified oxygen D. Assist in intubating the client and beginning mechanical ventilation 96- A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which of the following actions should the nurse take next? A. Providing pin care B. Medicating the client C. Notifying the physician Correct D. Removing some weight from the traction 97 -A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse A. Bivalve the cast B. Ask the physician to reapply the cast C. Use a nail file to smooth the rough edges D. Place small pieces of tape over the rough edges of the cast C 98 -A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it's probably cancer. Does this mean I'm going to die?" The nurse interprets the client's initial reaction as: A. Fear B. Denial C. Acceptance D. Preoccupation with self 99 -A nurse notes documentation in the client's medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which of the following findings does the nurse expect to note? A. B. C. D. 100- A nurse is providing instruction in how to perform Kegel exercises to a client with stress incontinence. The nurse tells the client to: A. Always perform the exercises while lying down B. Expect an improvement in the control of urine in about 1 week C. Tighten the pelvic muscles for as long as 5 minutes, three or four times a day D. Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10 101 -Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which of the following occurrences does the nurse tell the client to report to the physician if she experiences them while taking the medication? A. Cough B. Fatigue and lethargy C. Dizziness and fatigue D. Numbness and tingling of the fingers or toes 102 -A client with post-traumatic stress disorder tells the nurse that he has stopped taking his prescribed medication because he didn't like how the medication was making him feel. Which of the following initial responses by the nurse is appropriate? A. "That's all right. I'd stop, too, if it made me feel funny." B. "Tell me more about how the medication was making you feel." C. "Did you let your doctor know that you stopped taking the medication?" D. "It doesn't make sense to stop the medication. I don't know why you took it upon yourself to do that." 103- A nurse provides information to a client with peripheral vascular disease about ways to limit the disease's progression. Which of the following measures does the nurse tell the client to take? Select all that apply. A. Crossing the legs at the ankles only B. Engaging in exercise such as walking on a daily basis C. Washing the feet daily with a mild soap and drying them well D. Inspecting the feet at least once a week for injuries, especially abrasions E. Using a heating pad on the legs to help keep the blood vessels dilated 104 -A client with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs? A. Providing food and fluid as the client requests B. Offering high-calorie and high-protein foods and fluids frequently throughout the day C. Completing the dietary menu for the client to ensure that adequate nutrition is provided D. Weighing the client daily so that the client may determine whether the nutritional plan is working 105 -Disulfiram (Antabuse) is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication and tells the client: A. That driving is prohibited while the client is taking the medication B. To take the medication immediately if the desire to drink alcohol occurs C. That the effect of the medication ends as soon as the client stops taking the medication D. That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol 106 A client with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, "I can't draw or paint." Which of the following responses by the nurse is therapeutic? A. "Why don't you really want to attend?" B. "This is what your physician has prescribed for you as part of the treatment plan." C. "OK, let's have you attend music therapy. You can sing there. How does that sound?" D. "Perhaps you could attend and talk to the other clients and see what they're drawing and painting." 107 A hospitalized female client with mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse? A. "Why are you saying that?" B. "Stop saying that. It's not true!" C. "You wouldn't like someone saying that to you. Would you?" D. "Don't say that. If you can't control yourself, we'll help you." 108- A nurse working the evening shift is helping clients get ready for sleep. A female client with mania is hyperactive and pacing the hallway. The appropriate nursing action is to: A. Stay with the client and observe her behavior B. Take the client to the bathroom and provide her with a warm bath C. Tell the client that it is time for sleep and that she needs to go to her room D. Tell the client that other clients are trying to sleep and that she is being disruptive 109 -Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information? A. "I need to limit my intake of fluids while I'm taking this medication." B. "I need to stop the medication and call my doctor if I have severe diarrhea." Correct C. "I can expect skin redness and a rash when I take this medication." D. "I may get a burning feeling in my throat, but it's normal and will go away." 110 -A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which of the following behaviors is a characteristic of the disorder? A. Neediness B. Perfectionism C. Preoccupation with details D. Hypersensitivity to negative evaluation 111 -A female client admitted to the mental health unit tells the nurse that she cannot leave the house without checking to be sure that she has shut off the coffee maker and unplugged her curling iron. The client states that she even leaves the house, gets into her car, and then has to go back into the house to check these appliances again and that these behaviors are interfering with her work and social commitments. With which of the following anxiety disorders does the nurse associate this client's symptoms? A. Agoraphobia B. Avoidant personality disorder C. Obsessive-compulsive disorder D. Dependent personality disorder 112 -A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan of care? A. Inflexible and rigid B. Self-sacrificing and submissive C. Highly critical of self and others D. Projecting blame, possibly becoming hostile 113 -A client on the mental health unit says to the nurse, "Everything is contaminated." The client scrubs her hands if she is forced to touch any object. While planning care, the nurse remembers that compulsive behavior: A. Temporarily eases anxiety in the client B. Is an attempt on the client's part to punish herself C. Is an attempt on the client's part to seek the attention of others D. Is a response by the client to voices telling her that everything is contaminated and that she must engage in this behavior 114 -A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine. What is the priority response by the nurse? A. Assessing the client for organic causes of loss of arm movement B. Calling the crisis intervention team and asking them to assess the client C. Performing active and passive range-of-motion (ROM) exercises of the client's arms D. Asking the client to move his arms and documenting the loss of movement he has experienced 115 -A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar disorder. What does the nurse plan to do first? A. Perform the physical assessment B. Tell the client about the nursing unit rules C. Establish a trusting nurse-client relationship D. Tell the client that he or she will have to participate in self-care 116 -A client arrives in the emergency department and tells the nurse that she is experiencing tingling in both hands and is unable to move her fingers. The client states that she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier her husband told her that he wanted a separation and that she would have to support herself financially. The nurse concludes that this client is exhibiting signs compatible with: A. Severe anxiety B. Conversion disorder C. Posttraumatic stress disorder (PTSD) D. Obsessive-compulsive disorder 117 -A client experiencing delusions says to the nurse, "I am the only one who can save the world from all of the terrorists." What is the appropriate response by the nurse? A. "Tell me your plan for saving the world." B. "Why do you think that you can accomplish this by yourself?" C. "I don't think anyone can save the world from the terrorists by himself." D. "You must be powerful. Do you really believe that you can do this by yourself?" 118- A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply. A. Eat foods that are low in fat and protein B. Obtain pneumococcal and influenza vaccines C. Drink copious amounts of fluid and void frequently D. Avoid contact with any individual who has signs or symptoms of a cold E. Avoid contact with all individuals other than immediate family members 119- A client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall out?" The nurse responds by telling the client that: A. Her hair will definitely fall out B. She should not be worrying about her hair at this point C. Her hair may fall out but will regrow after the chemotherapy is discontinued D. Vigorous hair-brushing is important while the client is undergoing chemotherapy to prevent hair loss 120 -A nurse has given a client with viral hepatitis instructions about home care. Which of the following statements by the client indicates to the nurse that the client needs further teaching? A. "I can't drink alcohol." B. "I have to avoid having sex until the test for antibodies comes back negative." C. "I need to rest a lot during the day and get enough sleep at night." D. "I need to eat three meals a day with foods high in protein, fat, and carbs." 121- A nurse provides home care instructions to a client who has undergone fluorescein angiography. The nurse determines that the client needs further instruction if the client states that he must: A. Drink fluids to eliminate the dye B. Contact the physician if the skin appears yellow C. Expect that the urine will be bright green until the dye has been excreted D. Wear sunglasses and avoid direct sunlight until pupil dilation returns to normal 122 -An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which of the following characteristics of the disorder does the nurse expect the client to exhibit? Select all that apply. A. Nausea B. Eye pain C. Vomiting D. Headache E. Diminished central vision F. Increased light perception 123 - A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client? A. 8 mm Hg B. 14 mm Hg C. 20 mm Hg D. 28 mm Hg 124- An emergency department nurse assessing a client with Bell's palsy collects subjective and objective data. Which of the following findings does the nurse expect to note? A. A symmetrical smile B. Tightening of all facial muscles C. Ability to wrinkle the forehead on request D. Complaints of inability to close the eye on the affected side 125 A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate? A. Asking the child to describe the intensity of the pain B. Asking the child to use a numeric rating scale of 0 to 100 C. Asking the child whether the patient-controlled analgesia (PCA) pump is relieving the pain D. Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain 126 A school nurse observing a child with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation? A. Contacting the child's physician to report the findings B. Administering acetaminophen (Tylenol) to the child to relieve the pain C. Asking that the child not attend the physical education class until the neck pain has subsided D. Teaching the child how to use peripads to prevent embarrassment resulting from loss of bladder control 127 -A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication? A. "When was your last menstrual period?" B. "When was your last bowel movement?" C. "Are you having any difficulty hearing?" D. "Are you having any difficulty breathing?" 128 -A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction? A. "It's important to rotate injection sites." B. "I need to store the insulin in a cool, dry place." C. "I need to keep any unopened bottles of insulin in the freezer." D. "I need to check the expiration date on the insulin before I use it." 129 -A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. The nurse tells the client that this blood test: A. Is a measure of the client's hematocrit level B. Is a measure of the client's hemoglobin level C. Helps predict the risk for the development of chronic complications of diabetes mellitus D. Provides a determination of short-term glycemic control in the client with diabetes mellitus 130- A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't need your help!" What is the appropriate way for the nurse to document this occurrence in the client's record? A. Writing that the client is very agitated B. Writing that the client yelled at the nurse C. Writing that the client is able to perform her own care D. Writing down the client's words and placing them in quotation marks 131 A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction will be admitted from the emergency department. Which item does the nurse give priority to placing at the client's bedside? A. Bedside commode B. Suctioning equipment C. Electrocardiography machine D. Oxygen cannula and flowmeter 132 -Cascara sagrada has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication and tells the client to: A. Increase fluid intake B. Consume low-fiber foods C. Consume foods that are low in potassium D. Contact the physician if the urine turns yellow-brown [Show More]
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