Texas A&M University, Corpus Christi NURS 4470 2019 HESI EXIT V1 1)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

Texas A&M University, Corpus Christi

NURS 4470

2019 HESI EXIT V1

1)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.

notify the health care provider if it should decrease.

2.            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

3.            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

 

4.            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

5.            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

6.            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

7.            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.

 

8.            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.

 

9.            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

 

10.          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

 

 

11.          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

 

12.          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

 

 

13.          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

 

 

14.          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

 

 

15.          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

 

 

16.          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."

 

17.          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

 

 

18.          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

 

 

19.          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

 

20.          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

 

21.          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

 

22.          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

 

 

23.          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

 

24.          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.

 

25.          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.

 

 

26.          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

 

27.          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

 

28.          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."

 

29.          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

 

 

 

30.          Which of these observations made by the nurse during an excretory urogram indicate

a complicaton?

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.”

 

 

31.          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."

 

32.          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

 

33.          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

 

34.          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

 

 

35.          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

 

36.          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

 

 

37.          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

 

38.          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

 

 

39.          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

 

 

40.          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

 

 

41.          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

 

 

42.          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

 

43.          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

 

44.          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?

 

A)           Clamp the chest tube

B)            Call the surgeon immediately

C)            Prepare for blood transfusion

D)           Continue to monitor the rate of drainage

 

 

45.          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

46.          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

47.          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

48.          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.

 

 

49.          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

50.          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 skip

 

51.          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 Skip

52.          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

 

53.          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."

54.          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)           Dsypnea, nasal congestion

55.          A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours

for pain. In checking the client, which finding suggests a side effect of the analgesic?

A)           Bruising at the operative site

B)            Elevated heart rate

C)            Decreased platelet count

D)           No bowel movement for 3 days Skip

56.          A client is being maintained on heparin therapy for deep vein thrombosis. The nurse

must closely monitor which of the following laboratory values?

A)           Bleeding time

B)            Platelet count

C)            Activated PTT

D)           Clotting time

57.          A client with amyotrophic lateral sclerosis has a percutaneous endoscopic

gastrostomy (PEG) tube for the administration of feedings and medications. Which

 

nursing action is appropriate?

A)           Pulverize all medications to a powdery condition

B)            Squeeze the tube before using it to break up stagnant liquids

C)            Cleanse the skin around the tube daily with hydrogen peroxide

D)           Flush adequately with water before and after using the tube Skip

 

58.          The nurse has given discharge instructions to parents of a child on phenytoin

(Dilantin). Which of the following statements suggests that the teaching was effective?

A)           ”We will call the health care provider if the child develops acne."

B)            ”Our child should brush and floss carefully after every meal."

C)            ”We will skip the next dose if vomiting or fever occur."

D)           ”When our child is seizure-free for 6 months, we can stop the medication."

59.          Although non steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are

beneficial in managing arthritis pain, the nurse should caution clients about which of the

following common side effects?

A)           Urinary incontinence

B)            Constipation

C)            Nystagmus

D)           Occult bleeding

60.          The nurse is caring for a client with clinical depression who is receiving a MAO

inhibitor. When providing instructions about precautions with this medication, which

action should the nurse stress to the client as important?

A)           Avoid chocolate and cheese

B)            Take frequent naps

C)            Take the medication with milk

D)           Avoid walking without assistance

61.          A parent asks the school nurse how to eliminate lice from their child.

What is the

most appropriate response by the nurse?

A)           Cut the child's hair short to remove the nits

B)            Apply warm soaks to the head twice daily

 

C)            Wash the child's linen and clothing in a bleach solution

D)           Application of pediculicides

62.          The nurse is teaching a client about precautions with Coumadin therapy. The client

should be instructed to avoid which over-the-counter medication?

A)           Non-steroidal anti-inflammatory drugs

B)            Cough medicines with guaifenesin

C)            Histamine blockers

D)           Laxatives containing magnesium salts

63.          A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone

(Aldactone). The nurse understands that this medication spares elimination of which

element?

A)           Sodium

B)            Potassium

C)            Phosphate

D)           Albumin

64.          The nurse is caring for a client receiving a blood transfusion who develops urticaria

one-half hour after the transfusion has begun. What is the first action the nurse should

take?

A)           Stop the infusion

B)            Slow the rate of infusion

C)            Take vital signs and observe for further deterioration

D)           Administer Benadryl and continue the infusion

 

65.          Discharge instructions for a client taking alprazolam (Xanax) should include which of

the following?

A)           Sedative hypnotics are effective analgesics

B)            Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares

C)            Caffeine beverages can increase the effect of sedative hypnotics

D)           Avoidance of excessive exercise and high temperature is recommended

66.          A client has received 2 units of whole blood today following an episode of GI

 

bleeding. Which of the following laboratory reports would the nurse monitor most

closely?

A)           Bleeding time

B)            Hemoglobin and hematocrit

C)            White blood cells

D)           Platelets

67.          A client is receiving intravenous heparin therapy. What medication should the

nurse have available in the event of an overdose of heparin?

A)           Protamine

B)            Amicar

C)            Imferon

D)           Diltiazem

68.          The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus.

Which statement by the client indicates a need for further teaching?

A)           "I use a sliding scale to adjust regular insulin to my sugar level."

B)            "Since my eyesight is so bad, I ask the nurse to fill several syringes."

C)            "I keep my regular insulin bottle in the refrigerator."

D)           "I always make sure to shake the NPH bottle hard to mix it well."

 

69.          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

70.          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

 

71.          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

72.          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

73.          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

74.          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

75.          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

 

76.          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

77.          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

 

78.          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

79.          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

80.          When administering enteral feeding to a client via a jejunostomy tube, the nurse

should administer the formula

A)           Every four to six hours

B)            Continuously

C)            In a bolus

D)           Every hour

 

81.          The nurse is teaching an 87 year-old client methods for maintaining regular bowel

movements. The nurse would caution the client to AVOID

A)           Glycerine suppositories

B)            Fiber supplements

C)            Laxatives

D)           Stool softeners

82.          A client with diarrhea should avoid which of the following?

A)           Orange juice

B)            Tuna

C)            Eggs

D)           Macaroni

83.          Which statement best describes the effects of immobility in children?

A)           Immobility prevents the progression of language and fine motor development

B)            Immobility in children has similar physical effects to those found in adults

C)            Children are more susceptible to the effects of immobility than are adults

D)           Children are likely to have prolonged immobility with subsequent complications

 

84.          A nurse is providing care to a 63 year-old client with pneumonia.

Which intervention

promotes the client’s comfort?

A)           Increase oral fluid intake

B)            Encourage visits from family and friends

C)            Keep conversations short

D)           Monitor vital signs frequently

85.          After a myocardial infarction, a client is placed on a sodium restricted diet. When the

nurse is teaching the client about the diet, which meal plan would be the most appropriate

A)           3 oz. broiled fish, 1 baked potato, . cup canned beets, 1 orange, and milk

B)            3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple

C)            A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice

 

D)           3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange

 

86.          The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings

include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are

elevated. What dietary modifications are most appropriate?

A)           Decreased carbohydrates and fat

B)            Decreased sodium and potassium

C)            Increased potassium and protein

D)           Increased sodium and fluids

 

87.          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

 

88.          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

 

89.          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

 

90.          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

 

91.          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

 

92.          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

 

93.          A nurse who is reassigned to the emergency department needs to understand that

gastric lavage is a priority in which situation?

A)           An infant who has been identified to have botulism

B)            A toddler who ate a number of ibuprofen tablets

C)            A preschooler who swallowed powdered plant food

D)           A school aged child who took a handful of vitamins

 

94.          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

 

95.          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

 

96.          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

 

97.          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.

 

98.          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

 

99.          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