Nevada State College: BIOLOGY 301 BS 1343 HESI exit exam RN VERSION 3,100% CORRECT

Nevada State College: BIOLOGY 301 BS 1343 HESI exit exam RN VERSION 3 HESI EXIT VERSION 3 1. The nurse is reviewing medical prescriptions for newly admitted clients. It would be a priority for the nurse to follow up with the physician if a client with (a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene) prescribed (b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions(c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen) (d) sensitivity to Penicillin is prescribed Zithromax (azithromycin) 2. The nurse should intervene if the nurse notes a staff member (a) obtaining a clients consent prior to their operative procedure after receiving Ativan (lorazepam) (b) placing a client on the affected side following surgical repair of a retinal detachment (c) handling a wet cast with the palms of the hands (d) using a broad base of support while transferring a client 3. The community health nurse is caring for the following clients. It would be a priority for the nurse to initiate a multidisciplinary conference for the client who is (a) 12 years old with Autism who is starting a new school and recently had a URI (upper respiratory tract infection) (b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent Hemoglobin A1c of 13% (c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and employed as a mail carrier (d) 70 years old, has schizophrenia, lives alone and reports hearing non threatening voices. 4. The nurse from the postpartum unit has been temporarily assigned to the medical surgical unit. It would be most appropriate to assign this nurse to the client who* (a) has returned from right total hip replacement surgery four hours ago (b) is being observed for increased intracranial pressure (c) had surgery two hours ago to remove the appendix (d) is two weeks post partum being maintained on a mechanical ventilator for respiratory failure 5. The nurse in a well baby clinic has assessed several children today. It would be a priority for the nurse to suggest follow up for the child who is (a) 2 months old with a positive babinski refl ex (b) 5 months old and does not hold their own bottle (c) 10 months old who cries around strangers (d) 18 months old who needs support while ambulating 6. The nurse is caring for a mechanically ventilated client who was declared brain dead. An Advance Directive is not documented on the medical record. It would be most appropriate to obtain consent for organ donation from the (a) client’s primary care provider (b) client’s nurse manager (c) closest living family member (d) hospital’s ethics committee 7. The nurse has received report on four clients. The nurse should fi rst assess the client who has* (a) Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 90% (b) Parkinson’s Disease and is demanding to leave the hospital against medical advice (AMA) (c) been admitted with suspected Guillian-Barre´ Syndrome and has begun plasmapheresis therapy (d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+) 8. It would be appropriate to assign which of these tasks to the CNA? (a) Feeding a client who is experiencing dysphagia (b) One-on-one client observation for safety (c) Removal of an indwelling catheter (d) Performing a simple dressing change 9. The nurse should intervene if a staff member is observed (a) discussing a client’s diagnosis with visiting family members (b) collaborating with another nurse to review a prescription for blood transfusion (c) interrupting other staff members discussing a client in the cafeteria (d) reviewing a clients lab values with the nutritionist 10. The nurse is preparing a staff presentation on legal and ethical issues in nursing. The nurse would be correct to include which of the following examples? (a) Putting a client in a geriatric chair with the lap tray in front of the client in the day room to watch television is false imprisonment (b) Telling a client that you will put in a feeding tube if the client does not eat is an example of battery (c) Telling a client with bipolar disorder who is suicidal that they have a right to refuse to take their medications is an example of malpractice (d) Placing hands on a client who says “do not touch me” is an example of assault 11. The nurse from the pediatric unit has been temporarily assigned to the Emergency Department. It would be most appropriate to assign that nurse to the client who* (a) reports epigastric pain that “feels like indigestion” (b) has back pain and a pulsating abdominal mass (c) is HIV+ reporting vomiting and diarrhea (d) presents with lower abdominal pain and is six weeks pregnant 12. Four clients recently returned to the unit following invasive diagnostic testing. The nurse should immediately intervene if one of the clients (a) reports blood tinged sputum following a bronchoscopy (b) has decreased abdominal girth following paracentesis (c) reports a headache following a lumbar puncture (d) is observed flexing and extending the legs two hours after cardiac catheterization 13. The nurse is made aware of the following situations. The nurse should fi rst check the client who (a) had a transurethral prostatectomy (TURP) and is reporting urinary dribbling two hours after the indwelling catheter is removed (b) has cervical traction and is moving the legs by fl exing and extending the feet (c) has Alzheimer’s disease (stage 1) and was returned to the room after being found wandering in the hallway (d) has a history of partial seizures and is sitting in the bed picking at the clothing and smacking the lips 14. The nurse in a community health clinic is talking with the parent of a child with Celiac Disease. Which of the following statements would require follow-up by the nurse for additional teaching? (a) “This weekend we are going to a seafood restaurant.” (b) “I can feed my child oatmeal and eggs for breakfast.” (c) “My child loves to eat rice and chicken for dinner.” (d) “Last night we ate fi sh with corn for dinner.” 15. The charge nurse is observing a Licensed Practical Nurse (LPN) performing care for assigned clients. Follow up will be required if the LPN*: (a) assesses a client’s apical pulse before administering Digoxin (lanoxin) (b) elevates the client’s stump on a pillow eight hours after amputation (c) dons a clean glove on the dominant hand before tracheal suctioning (d) positions a client on the operative side following a pneumonectomy 16. The nurse at a health promotion fair has taught a group of parents about car seat and seat belt safety. Which of the following statements, if made by the parent, would indicate a correct understanding of the information given? (a) “I will place my newborn infant in a rear facing car seat in the middle of the rear seat.” (b) “I will wear a lap seat belt high on my belly since I am 8 months pregnant.” (c) “I can use a front-facing car seat once my baby weighs 15 pounds.” (d) “I can allow my six-year-old to use a seat belt in the front passenger seat.” 17. The nurse is caring for a client being treated for Vancomycin Resistant Enterococcus (VRE). The nurse should place the client on (a) contact precautions (b) droplet precautions (c) protective precautions (d) airborne precautions 18. The nurse is caring for a client with a Vancomycin Resistant Enterococcus (VRE) wound infection. Which of the following actions would be appropriate for the nurse to take? (a) Wear a particulate respirator mask when providing wound care (b) Instruct visitors not to bring fl owers into the client’s room (c) Place the client in a private room with negative air pressure (d) Wear a disposable gown when changing the client’s dressing 19. The nurse should initiate protective precautions for a client who has a (a) Red Blood Cell Count (RBC) of 3,900/mm3 (b) Platelet count of 400,000µ/L (c) Hemoglobin (Hgb) 9.0 g/dl (d) White Blood Cell Count (WBC) 2,500/mm3 20. The nurse has provided health promotion teaching for a group of clients who were recently diagnosed with the Human immunodefi ciency virus (HIV). Which statement, if made by one of the clients, would require further teaching? (a) “I am glad that I can still clean my parakeet’s cage.” (b) “I will not go to the parade this weekend.” (c) “I will increase protein in my diet.” (d) “I will miss not being able to work in my garden.” 21. The nurse in the emergency department is caring for clients admitted following a rescue from a burning bus. The nurse should fi rst see the client who (a) has the tibia bone protruding through the skin and is in severe pain (b) has third degree burns of the left foot and is crying (c) is unconscious, pulseless, and has dilated pupils (d) has soot on the face and the nares and is coughing A nurse is observing a newly-hired nurse provide care for assigned clients. The nurse should follow up if the newly-hired nurse is observed (a) wearing gloves when taking the blood pressure of a client with disseminated varicella zoster (b) cleansing the wound from the outer surface to the inner surface for a client whose wound is infected with a multi-drug resistant organism (c) washing the hands with the fi ngertips pointed downward before providing care for a client on protective precautions (d) removing the gloves before removing the gown when leaving a room of a client who is on contact precautions 23. The nurse is caring for a client who has been diagnosed with rheumatoid arthritis. The nurse should anticipate that the client will initially be prescribed (a) Disease-modifying rheumatic agents (DMARDs) (b) Nonselective anti-infl ammatory drugs (NSAIDs) (c) Long-term corticosteroids (d) Biologic Response Modifi ers 24. The nurse is assessing a 2-month-old-infant at a well baby clinic. The nurse should anticipate the infant should (a) roll from prone to back (b) have no head lag (c) smile socially (d) have no tonic neck refl ex 25. The nurse is teaching a class on infant nutrition. The nurse should instruct parents to introduce (a) fruit juices at 3 months (b) honey sweetened water at 6 months (c) pureed chicken at 7 months (d) whole milk at 9 months 26. The nurse is caring for a 7-year-old who has thrombocytopenia and is on protective precautions. Which of the following would be an appropriate toy for the nurse to provide to the client? (a) Finger paints and paper (b) A rubber ball and bat (c) A board game (d) A stuffed toy 27. The nurse on a pediatric unit has been informed that the following clients are being admitted. The nurse should fi rst plan to assess the client who is* (a) 2 years old, has a temperature of 100.8 F and a blood pressure of 68/44 (b) 4 years old with a history of asthma and has a peak expiratory fl ow rate (PERF) of 81% (c) 5 years old, has a fracture of the tibia and is reporting pain rated 7 on a pain scale of 0 (no pain) to 10 (severe pain) (d) 7 years old with ulcerative colitis and has had 15 blood tinged stools today 28. The nurse is providing discharge instructions to the parents of an infant who has a cleft lip. The nurse should instruct the parents to (a) place the infant in a prone position after each feeding (b) encourage the parents to provide the infant rest periods during feedings (c) regularly offer the infant a pacifi er to enhance the sucking refl ex (d) elevate the child’s head forty fi ve degrees during feeding 29. The nurse is assessing a 3-year-old during a well-child visit. During the visit the boy says to his mother, “Mommy, I love you. I’m going to marry you.” The nurse should (a) suggest to the mother not to encourage these types of statements (b) explain to the child that he will not be able to marry his mother even though he loves her (c) tell the mother that this statement is appropriate for his stage of development (d) recommend that the mother provide more opportunities for her son to play with other 3-year-old boys 30. The nurse is assessing a child with coarctation of the aorta. Which of the following would be an expected fi nding? (a) diminished blood pressure in the upper extremities (b) excessive weight gain (c) high pitched murmur (d) absence of femoral pulses 31. The nurse is caring for a child with an acyanotic heart defect. Which of the following would be an expected fi nding. Select all that apply. (a) poor suck refl ex (b) tachycardia (c) increased respiratory rate (d) bradycardia (e) fainting spells (f) delayed growth and development 32. The nurse is teaching a new mother about immunizations. Which of the following should the nurse include in the teaching? (a) “Your baby should wait six months to receive any immunizations since the baby was born preterm.” (b) “Your baby will receive the fi rst hepatitis B vaccine after one year of age.” (c) “Acellular Pertussis vaccine has less side effects than whole-cell pertussis vaccine.” (d) The Haemophilus Infl uenza Type b (HIB) is given annually to protect against the fl u.” 33. The mother of an infant tells the nurse that the baby has not been tolerating feedings lately and she noticed an olive-shaped mass in the infant’s abdomen. The nurse recognizes that this could be an expected fi nding if the infant has (a) intussusception (b) Hirschsprung’s disease (c) umbilical hernia (d) pyloric stenosis 34. The nurse is teaching a group of parents about the expected growth and development of three-year-old children. The nurse should include that a three- year-old should (a) discriminate between fantasy and reality (b) ride a tricycle independently (c) have a vocabulary of 7,000 words (d) play in a group of two or three with one being the leader 35. The nurse and the nursing assistant are caring for a group of clients. Which of the following client care activities should the nurse assign to the nursing assistant? Select all that apply. (a) reinforcing the dressing of a client who has a decubitus ulcer (b) monitoring the vital signs of a client who had a myocardial infarction 12 hours ago and is being transferred from the coronary care unit (c) administering a prescribed Fleet’s enema to a client who will undergo a colonoscopy in two hours (d) placing a client who had an above the knee amputation 24 hours ago in a prone position (e) assisting a client who had a colon resection 36 hours ago to ambulate (f) showing a client who had a vaginal hysterectomy 36 hours ago how to perform perineal care 36. The nurse is caring for a client with Acquired immunodefi ciency syndrome (AIDS) who was started on Zidovidine (AZT). It would be important for the nurse to assess (a) blood ammonia serum (b) serum potassium (c) complete blood count (CBC) (d) serum uric acid 37. The nurse is performing an abdominal assessment. Indicate the correct sequence the nurse should use to perform this assessment. (a) percussion (b) palpation (c) auscultation (d) inspection Answer 38. The nurse has become aware of the following client situations. The nurse should fi rst assess the client who* (a) had received a unit of packed red blood cells four hours ago and is requesting a bedpan (b) had an abdominal hysterectomy yesterday and is reporting calf pain (c) has history of multiple sclerosis and is reporting diplopia (d) had a tonsillectomy three hours ago and is reporting a sore throat 39. The nurse is caring for a client who has been prescribed 1,000 ml of Ringer’s Lactate to infuse over 8 hours. The available intravenous set delivers 10 drops per milliliter. How many drops per minute should the nurse set the intravenous controller to administer? Answer 40. The primary health care provider has prescribed an oral solution of Potassium Chloride (KCL) 20 mEq PO, QD. The drug available is Potassium Chloride 10 mEq/15ml. How many ml should the nurse administer? Answer 41. The primary health care provider has prescribed Heparin 5000 units SC. The drug available is heparin sodium 7500units/ml. Choose all of the correct answers for nursing considerations for the administration of heparin sodium. (a) administer the heparin in the abdomen (b) administer 0.5ml of heparin sodium (c) aspirate after inserting the needle (d) use a 1 inch 21 gauge needle (e) refrain from massaging the site after administer heparin (f) remember that protamine sulfate is the antidote for heparin 42. The nurse has attended a staff development conference on cultural considerations for clients receiving hospice care. Which of the following statements if made by the nurse would require follow-up? (a) The family of a client of the Buddhist faith may ask for a priest to be present at the time of death (b) The family of a client of the Jewish faith may request to have mirrors covered after the death of the client (c) The family of a client of the Muslim faith may request that the body of the client be turned to face the East at the time of the client’s death (d) The family of a client of the Hindu faith may request that the client body be bathed after the client’s death 43. The nurse is caring for a client with bipolar disorder who has Lithium (Lithotabs) prescribed. The nurse should suggest that the client have which of the following snacks? (a) A fresh fruit cup (b) Coffee and oatmeal cookies (c) Tuna fi sh salad on saltine crackers (d) Raw vegetables 44. The nurse has provided discharge instructions for a client who has been prescribed Digoxin (Lanoxin). It would require follow up by the nurse if the client says (a) “I will consult my primary health care provider before taking medications that contain aspirin.” (b) “I will not take any antacids within two hours of taking the digoxin.” (c) “I will avoid fruits such as avocados, grapefruit and cantaloupe.” (d) “I will remember that any visual disturbance can be a sign of digitalis toxicity.” 45. The nurse is caring for a client who has bumetanide (Bumex) prescribed. The nurse should suggest that the client include which of the following foods in the diet? (a) Apricots (b) Organ meats (c) Sardines (d) Apples 46. The nurse is providing teaching for a client with ulcerative colitis. Select all of the following that the nurse should include in the teaching (a) steatorrhea commonly occurs or excessive secretion of fecal lipids is common (b) ulcerative colitis occurs most frequently in Jewish males 30-50 years of age (c) a diet high in residue and low in complex carbohydrates is helpful in controlling symptoms (d) Corticosteroids may be prescribed during an exacerbation (e) metronidazole (Flagyl) and ciprofl oxacin (Cipro) are antibiotics commonly used during acute exacerbations (f) eating small frequent meals and lying down after eating promotes absorption of nutrients 47. The nurse is precepting a newly-hired nurse who is caring for a client receiving a prescribed continuous nasogastric feeding. The nurse should intervene immediately if the newly-hired nurse (a) instills 30cc of normal saline into the feeding tube while auscultating over the stomach for bowel sounds (b) checks the pH of the 60ml gastric aspirate removed from the feeding tube (c) maintains the client with the head of the bed elevated at 45 degrees (d) hangs four hours worth of prescribed feeding formula in an open delivery system 48. The nurse is observing a staff member caring for clients. It would require immediate intervention if the nurse observes the staff member (a) placing a client who had an above-the-knee amputation (AKA) 24 hours ago in a prone position (b) keeping the head of the bed elevated for the client who had an supratentorial craniotomy 12 hours ago (c) giving orange juice to a client who has a clear liquid diet prescribed (d) removing all liquids from the tray before giving the tray to a client who has dumping syndrome 49. The primary health care provider has prescribed ampicillin (Omnipen) 0.5 GM PO Q6H to a 15 month old toddler who weighs 22 pounds. The drug available is ampicillin suspension 250 mg/5 ml. The recommended dosage is 50 mg/kg/ day every 6 to 8 hours. The nurse should (a) call the primary health care provider to report that the prescription exceeds the recommended dosage (b) determine if the toddler has previously had a penicillin or a cephalosporin prescribed (c) give the toddler the ampicillin mixed with applesauce (d) wait until the result of the throat culture obtained one hour ago is reported 50. The nurse is instructing a class for parents of children diagnosed with sickle cell anemia. The nurse should instruct the parents to have the children avoid (a) exposure to hot water (b) other children with infections (c) medications containing aspirin (d) non - contact sports 51. The nurse is assessing a 5-month-old infant. The nurse should expect the infant to (a) roll from abdomen to back (b) sit without support (c) say ‘mama’ and ‘dada’ (d) prefer use of one hand over the other 52. The home health care nurse is assigned to see four clients who all live within three miles of each other. The nurse should fi rst see the client who has (a) gastroesophageal refl ux disease (GERD) and is reporting a burning abdominal pain that is relieved by walking (b) cancer of the esophagus who has given away a favorite shirt since the last visit (c) regional enteritis (Crohn’s disease) who has an elevated temperature and is vomiting (d) a gastrostomy tube who will begin self-feeding for the fi rst time 53. A student nurse is administering magnesium hydroxide/aluminum hydrate (Maalox) prescribed as an antacid to a client. The nursing instructor should intervene if the student plans to administer the antacid (a) two hours after the client has eaten a meal (b) at the same time as a prescribed iron preparation (c) after briskly shaking the bottle of Maalox (d) when assessing the client for the presence of gastric pain 54. The nurse has attended a staff development conference on vitamins and minerals. Which of the following statements if made by the nurse would require follow-up? (a) “Vitamin B12 (cobalamin) supplement may be needed if a client has a gastrectomy.” (b) “Vitamin D (calciferol) is necessary for proper utilization of calcium and phosphorous.” (c) “Vitamin A can be found in squash, pumpkin, and carrots.” (d) “Vitamin B6 (pyridoxine) supplements are given to help prevent macular degeneration.” A nurse is caring for a two-month-old infant being evaluated for congenital hypothyroidism. The nurse should recognize which of the following fi ndings as being consistent with congenital hypothyroidism? (a) The infant sleeps for 6 hours at a time (b) The infant has a high-pitched cry (c) The infant has been having frequent loose stools (d) The infant has 3 + refl exes 56. The nurse in the emergency department is assessing a toddler who has swallowed some bleach. The toddler is crying. It would be a priority for the nurse to follow up if the parent says (a) “I brought the container of bleach with me.” (b) “I could not get my toddler to vomit.” (c) “I gave my toddler a tablespoonful of ipecac syrup.” (d) “I attempted to perform CPR to prevent my toddler from becoming unresponsive.” 57. The nurse is caring for a client who is ventilator dependent. The nurse is aware that the high pressure alarm can be sounded for various reasons. Select all reasons that could apply. (a) increased bronchial secretions (b) the presence of an air leak (c) the presence of a kink in the tubing (d) the client stops breathing spontaneously (e) acute bronchospasm (f) the client is biting the tube (g) the ventilator tubing is disconnected 58. The nurse is caring for a client who has a new colostomy. The colostomy stoma is red, moist and slightly raised. The nurse should (a) determine if the client is allergic to the skin barrier (b) apply petroleum jelly gauze around the stoma (c) document the condition of the stoma (d) assess the client’s temperature 59. The nurse has attended a staff development conference on medical treatments for various neurological disorders. Which of the following statements if made by the nurse would require follow-up? (a) “Clients with Guillain-Barre´ syndrome (GBS) often have plasmapheresis prescribed.” (b) “Myasthemia Gravis can be treated with short-acting anticholinesterase drugs.” (c) “Parkinson’s disease may have catechol O-methyltransferase (COMT) inhibitors prescribed along with levodopoa-carbidopa (Sinemet).” (d) “Clients with Multiple Sclerosis often receive Intravenous immunoglobulin G (IV IgG).” 60. The nurse has attended a staff development conference on Meniere’s Disease. Which of the following statements, if made by the nurse would require follow-up? (a) “Meniere’s Disease symptoms result from excess endolymphatic fl uid in the inner ear.” (b) “Clients with Meniere’s Disease are encouraged to have a low salt diet.” (c) “Assistive listening devices are required for clients with Meniere’s Disease.” (d) “Stress is suspected to have a role in Meniere’s Disease.” 61. The nurse is admitting a client to the emergency department who is reporting progressive visual impairment and loss of peripheral vision. The nurse should recognize that these symptoms are consistent with the medical diagnosis of (a) macular degeneration (b) closed angle glaucoma (c) senile cataract (d) retinal detachment 62. The nurse is caring for a client who has left ventricular failure. Which of the following should the nurse recognize as being consistent with this diagnosis? (a) 3+ pedal edema (b) jugular vein distention (c) oxygen saturation of 96% (d) wheezing during expiration 63. The nurse has attended a staff development conference on preparing clients for neurological diagnostic tests. Which of the following statements, if made by the nurse would require follow-up? (a) “The electromyogram (EMG) is performed by introducing small needle electrodes into muscles.” (b) “After having a Positron Emission Tomography (PET) of the head the client can resume normal activities.” (c) “The electroencephalogram (EEG) will require the client to be NPO for 12 hours before the test.” (d) “After the lumbar puncture (LP) the client will need to lie fl at for about 3 hours.” 64. The nurse has become aware of the following client situations. It would be a priority for the nurse to intervene if a client (a) who had a cervical radium implant inserted sixteen hours ago is placed on bed rest (b) who had transsphenoidal hypophysectomy twelve hours ago is drinking fl uids through a straw (c) who has received prescribed Lithium for the past three days is observed eating a pickle brought in by a family member (d) who had retinal detachment repaired using a gas bubble four hours ago is lying on the operative side postoperatively 65. The nurse is caring for a client who has oxalate kidney stones. The nurse should teach the client to avoid (a) Spinach and rhubarb (b) Mushrooms and rice (c) Shell fi sh and aged cheese (d) Organ meats and wine 66. A client with end stage renal disease (ESRD) is scheduled for hemodialysis in one hour. The nurse should notify the primary health care provider that the client has a (a) BUN of 60 mg/dl (b) Creatinine 3.5 mg/dl (c) Sodium 145 mEq/L (d) Potassium 6.8 mEq/L 67. The nurse is caring for a 49 year old female client who reports having frequent vaginal yeast infections. The client is 35% over her ideal body weight. The client has had several diagnostic blood tests prescribed. It would be a priority for the nurse to review the results for an elevated (a) fasting blood glucose (b) white blood count (c) hemoglobin (d) blood urea nitrogen 68. The nurse at a health clinic is screening male clients for testicular cancer. It would be a priority for the nurse to teach testicular self examination to (a) a 17-year-old college football player (b) a 39-year-old who smokes a pack of cigarettes day (c) a 55-year-old with benign prostatic hypertrophy (d) a 69-year-old with a family history of testicular cancer 69. The nurse is caring for a 72-year-old client who was recently diagnosed with metastatic breast cancer. The client is expressing feelings of depression and is asking the nurse, “Why me?” According to Erikson, which developmental stage is the client experiencing? (a) Industry vs. inferiority (b) Ego integrity vs. despair (c) Generativity vs. stagnation (d) Intimacy vs. isolation 70. The nurse is caring for several clients who have been prescribed diuretics. The nurse should teach about increasing the consumption of citrus fruits and bananas to the client who has been prescribed (a) amiloride (Midamor ) (b) spironolactone (Aldactone) (c) torsemide (Demadex) (d) triamterene (Dyrenium ) 71. The nurse in a health clinic is reviewing prescribed medications with several clients. It would be a priority for the nurse to follow up with the client who states (a) “I am taking losartan (Cozaar) to lower my blood pressure.” (b) “I crush my verapamil (Calan SR) to make it easier to swallow.” (c) “I try to avoid sudden position changes since I am taking hydralazine (Apresoline).” (d) “I will not use any salt substitutes since I am taking captopril (Capoten).” 72. The nurse is developing a plan of care for a client diagnosed with fi bromyalgia. Which nursing diagnosis should the nurse include? (a) Sleep pattern disturbance (b) Risk for infection (c) Fluid volume defi cit (d) Urge urinary incontinence 73. The nurse has attended a staff development conference on sexually transmitted diseases. Which of the following statements, if made by the nurse would require follow-up? (a) “During the primary stage of syphilis a lesion occurs at the site of infection called a chancre.” (b) “A client with HIV who has a reading of 5 or more on the mantoux test is considered to have a positive fi nding for pulmonary tuberculosis.” (c) “Gonorrhea is often asymptomatic in women but causes urinary frequency and dysuria in males.” (d) “Chlamydial infections are strongly linked with cervical cancer in women.” 74. The infection control nurse is making rounds on a Medical Surgical unit. The infection control nurse should immediately intervene if a nurse is observed (a) wearing a disposable surgical face mask when entering the room of a client with active pulmonary tuberculosis (b) keeping the door to the room closed of a client with disseminate varicella zoster (c) leaving a dedicated stethoscope in the room of a client with respiratory syncytial virus (d) wearing a gown, gloves, and mask while taking the blood pressure of a client with Ebola Virus 75. The nurse in a community health setting is assessing the following clients. It would be a priority for the nurse to utilize a multidisciplinary approach for the client who is* (a) 12 years old, with chicken pox and cannot attend school (b) 21 years old, pregnant, unemployed and has active pulmonary tuberculosis (c) 32 years old, a grade school teacher and is recovering from a sickle cell crisis (d) 74 years old, with mild Alzheimer’s disease and is in an assisted living residence 76. The nurse working in the labor and delivery room has become aware of the following client situations. The nurse should fi rst assess the client who is (a) in the fi rst phase of labor and the fetal heart rate ranges from 128 to 140 between contractions (b) in the fi rst phase of labor and the fetal heart rate is consistently beating at 132 beats per minute (c) in the third phase of labor and the fetal heart rate has decelerated to its lowest point at the acme of the contraction (d) in the third phase of labor and the contractions are lasting 60-70 seconds 77. The nurse is caring for postpartum clients who had vaginal deliveries within the last eight hours. The nurse should fi rst assess the client who (a) has a pulse rate of 66 beats per minute (b) has saturated one perineal pad in two hours (c) reports swelling in her right calf (d) asks if her baby can sleep in the nursery tonight 78. The nurse has become aware of the following client situations. It would be a priority for the nurse to follow-up if a client who (a) had a total knee replacement 24 hours ago is using continuous passive motion (CPM) exerciser while in a supine position (b) is scheduled for a myelogram in 4 hours and states “I can not drink any liquids until after the procedure is fi nished.” (c) had a total knee replacement 24 hours ago and is sitting in a fowlers position to eat a meal (d) had a pin inserted 4 hours ago for a fractured femur has a small amount of bright red bleeding at the pin site 79. The nurse is teaching a client about crutch walking. Which of the following statements if made by the client indicates a need for further teaching? (a) “My elbows should be fl exed 20 - 30 degrees, while walking.” (b) “When I climb stairs I advance my affected leg fi rst, with my crutches.” (c) “I do not apply pressure under my arm when I use my crutches.” (d) “W hen I am going to sit in a chair I put both crutches in the hand on my unaffected side.” 80. The nurse on an orthopedic unit has become aware of the following client situations. It would be a priority for the nurse to follow-up if a client who (a) had a total hip replacement 8 hours ago has had 100 ml of bloody drainage in the closed wound suction device (b) has an external fi xation device after a repair of a fractured femur is requesting pain medication (c) had an open reduction and internal fi xation (ORIF) of a fractured femur 12 hours ago has developed a small rash on the chest and neck (d) had a total hip replacement three hours ago has a temperature of 37.8° C (100.2° F) 81. The nurse is caring for a client with a soft tissue injury. The client reports using a herbal remedy for 3 weeks prior to seeking health care but can not remember what was taken. The nurse should recognize that which of the following herbal remedies can be utilized effectively for soft tissue injuries? (a) Saint John’s Wort (b) Kava Kava (c) Dong–Quai (d) Aloe Vera 82. A client with left-sided weakness following a cerebral vascular accident (CVA) is learning to ambulate with a cane. The nurse should teach the client to (a) hold the cane on the left side and move the cane with the right leg (b) hold the cane on the right side and move the cane with the left leg (c) hold the cane on the left side and move the cane with the left leg (d) hold the cane on the right side and move the cane with the right leg 83. The nurse has become aware of the following client situations. It would be a priority for the nurse to intervene if a client (a) scheduled for an EEG is washing the hair (b) is being transported to have a magnetic resonance image (MRI) test and is attached to a pulse oximeter (c) is being taught to hold the breath at intervals during a computerized tomography (CT Scan) (d) on protective precautions is eating soup brought in by a visitor 84. The nurse is reviewing laboratory data of the following clients. It would be a priority for the nurse to follow-up with the primary health care provider if a client with (a) coronary artery disease has a low density lipoprotein (LDL) level of 129mg/dl (b) primary hypertension has a sodium level of 144mEq/L (c) rhinosinusitis has a white blood count (WBC) of 11,500/ul (d) diabetes mellitus type 1 has a glycosylated hemoglobin (HbA1c) level of 12% 85. The nurse working on a maternity unit has become aware of the following client situations. It would be a priority for the nurse to intervene if a client states (a) “I will not take my terbutaline (Brethine) if my pulse is greater than 110 beats per minute.” (b) “It is normal for my 10 hour old baby to have blue feet and hands.” (c) “I cannot breast feed because my nipples are cracked and sore.” (d) “I have changed my perineal pad every two hours since I delivered my baby 12 hours ago.” 86. The nurse observes an adult collapse on the street. Indicate the correct sequence for the nurse to follow. (a) phone emergency medical system at 911 -2 (b) verify unresponsiveness -1 (c) check for breathing -4 (d) establish an airway using a head-tilt/chin-lift -3 Answer 87 A nurse is admitting a client with suspected pulmonary tuberculosis (TB). Which of the following actions should the nurse take? (a) wear a gown when taking the client’s health history (b) place the client on droplet precautions (c) keep the door to the client’s room closed (d) use disposable gloves when taking the client’s blood pressure 88. The charge nurse of a medical-surgical unit notices a nurse walking with an unsteady gait, slurred speech and a faint smell of alcohol on the breath immediately following a lunch break. The charge nurse’s priority action would be to* (a) notify the nursing supervisor (b) asking the nurse about recent alcohol consumption (c) complete an incident report (d) relieve the nurse of assigned clients 89. The staff members of an out patient clinic have successfully assisted the clients to safety during a fi re in the waiting area. Which action should the nurse perform next? (a) Close all open doors (b) Call for additional help (c) Attempt to extinguish the fi re (d) Assess the clients’ vital signs 90. While performing an assessment of a 3-year-old client, the nurse notices bruises in various stages of healing on the concealed surfaces of the body. Which action should the nurse take next? (a) document the locations of the bruises in the medical record (b) notify the primary health care provider (c) contact the local reporting agency for suspected child abuse (d) ask the parent to explain the injuries 91. The nurse in the emergency department is admitting a client who is hallucinating and reports insects crawling on the skin. The client’s pulse rate is 124 and the respiratory rate is 10. The nurse notes muscle twitching of the lower extremities. It would be a priority for the nurse to determine if the client has (a) a history of attention defi cit disorder (b) recently ingested cocaine (c) taken disulfi ram (Antabuse) within the past 24 hours (d) an allergy to anticholinergics 92. The nurse is developing a nursing care plan for a client who is in the manic phase of bipolar disorder. Which intervention should the nurse include in the plan of care? (a) Provide the client with fi nger foods (b) Engage the client in competitive games (c) Encourage the client to avoid foods that contain tyramine (d) Place the client on direct suicide observation 93. The primary health care provider has prescribed amitriptyline (Elavil) 150 mg P.O. daily for a client diagnosed with major depression. Choose all of the correct answers for nursing considerations for the administration of Elavil. (a) administer this medication with meals (b) teach the client that the appetite will be diminished (c) administer this medication in the morning (d) monitor the client for hypertension (e) Instruct the client that this medication may cause the development of a dry mouth (f) inform the client that this medication may cause photosensitivity A 45 year old client who was recently diagnosed with terminal cancer says to the nurse “If God could only let me live long enough to put my daughter through college, I wouldn’t mind dealing with this illness.” The nurse caring for this client recognizes this statement as refl ective of which stage of grieving? (a) Denial (b) Acceptance (c) Bargaining (d) Anger 95. The nurse on a psychiatric unit is caring for a client with paranoid schizophrenia who has lost 15 pounds within the past three weeks. The client accuses the staff of trying to poison all of the clients on the unit. Which of the following nursing interventions would be a priority for the nurse to include in the client’s plan of care? (a) Determine the client’s favorite foods (b) Offer the client small quantities of food at frequent intervals (c) Sit with the client during meals (d) Provide the client with pre-packaged foods that the client likes 96. The nurse is admitting a 20-year-old client with anorexia nervosa. The nurse should assess the client for (a) stained enamel of the teeth (b) lanugo-type hair on the body (c) persistent ringing in the ears (d) white patches on the tongue 97. The nurse is admitting a client with major depression. It would be a priority for the nurse to (a) determine if the client was voluntarily admitted (b) ask the client if suicide has been contemplated (c) have the client’s possessions searched for sharps (d) administer to the client the prescribed antidepressant 98. The nurse is caring for a client with disseminated intravascular coagulation (DIC) who is receiving a unit of packed red cells. Thirty minutes after the start of the transfusion, the client reports chills and fl ank pain. The nurse should fi rst (a) fl ush the intravenous tubing with normal saline (b) assess the client’s vital signs (c) stop the transfusion (d) notify the primary health care provider 99. The nurse is developing a teaching plan for a client with pulmonary tuberculosis who has been prescribed rifampin (Rifadin), isoniazid (INH), pyrazinamide (Tebrazid) and ethambutol (Myambutol). The nurse should include in the teaching plan that (a) the combination of drugs prescribed is necessary to decrease the risk of drug resistance (b) the medications should be taken on an empty stomach (c) the medications can be discontinued in one month (d) the client will require hepatic function tests every month 100. The nurse is reviewing a client’s arterial blood gas (ABG) results which reveal the following: pH: 7.35; PaO2: 75 mm Hg; PaCO2: 55 mm Hg; HCO3: 30 mEq/L. The nurse should recognize that this result is suggestive of which acid base imbalance? (a) compensated metabolic acidosis (b) compensated respiratory acidosis (c) compensated metabolic alkalosis (d) compensated respiratory alkalosis 101. The nurse in a well child clinic is taking the vital signs of a 4 year old client. The nurse obtains the following readings: temperature 98.2°F, pulse 110, respirations 22, blood pressure 86/60. The nurse should (a) ask if the parent knows what the child’s pulse rate is usually (b) encourage the child to rest for 10 minutes and reassess vital signs (c) document the fi ndings in the client’s medical record (d) notify the primary health care provider of the fi ndings 102. A nurse has become aware of the following client situations. Which of the following if observed shows that the UAP needs further teaching? The UAP (a) avoids washing the body of a Jewish client until thirty minutes after death (b) allows the family of a Buddhist client to chant ritual rites at the bedside of their deceased father (c) provides coffee and cookies for the visiting family of a Mormon client (d) removes a cup of tea from the breakfast tray of a Seventh Day Adventist client 103. A nurse has become aware of the following situations. Which should cause the greatest concern for the nurse? A client with (a) a bipolar disorder who is screaming at the nurses station (b) congestive heart failure has bi-pedal edema (c) a transurethral resection of the prostate (TURP) has blood tinged urine in the urinary bag (d) radon seed implants is seen ambulating in hall 104. The nurse is caring for clients who were recently removed from a falling building. Who would the nurse see fi rst? The client with (a) fi rst degree burns and a sprained left ankle (b) dilated pupils and a small laceration to the left ear (c) a fracture of the right tibia and abdominal pain (d) confusion and soft tissue injuries 105. A nurse is preparing assignments for the day. Which of the following clients should the nurse see fi rst? A (a) 48 y.o ventilator dependent client who needs a sputum specimen (b) 54 y.o on Bleomycin (Blenoxane) complaining of vomiting (c) 65 y.o with pneumonia who needs to start IV antibiotics (d) 72 y.o asthmatic complaining of SOB after using Albuterol (Ventolin) 106. A nurse working on a pediatric unit is made aware of the following situations. Which child is the priority to be seen fi rst? A (a) 1 year old with Tetralogy of Fallot with bluish discoloration to the lips while crying (b) 2 year old with renal failure with a potassium level of 6.4 mEq/L (c) 3 year old diagnosed with Rheumatic Heart Fever with an elevated ESR rate (d) 4 year old diagnosed with Rota-Virus having 5 bowel movements during an 8 hour shift 107. After receiving report from the night nurse, which of the following patients should the nurse see fi rst? (a) A 30- year old woman who is 38 weeks pregnant complaining of a small amount of vaginal bleeding (b) A 42- year old man with left sided weakness asking for assistance to the commode (c) A 55-year old woman complaining of chills who is scheduled for a total abdominal hysterectomy (d) A 77-year old man with a nasogastric tube who had a gastrectomy yesterday 108. Which of the following clients is appropriate to assign to an LPN for medication administration? * (a) A 25 year old in sickle cell crisis who will need Morphine intravenously (b) A 36 year old post operative client who is using a PCA pump (c) A 50 year old who will need Regular Insulin coverage for a glucose reading of 240mg/dl (d) A 60 year old who needs Dopamine intravenously for blood pressure management 109. The charge nurse is making assignments for the day. Which patient would you assign to the RN fl oated from the Pediatric unit to the Emergency Department? * (a) A 2 year old admitted with suspected ingestion of chlorine (b) A 5 year old being treated for Asthma that is not responding to bronchodilators (c) A 7 year old brought to the department following a motor vehicle accident (d) A 10 year old awaiting admission following cast placement 110. The Charge nurse is making assignments for the day. The team consists of the RN/LPN-LVN and UAP. Which client is appropriate to assign to the UAP? * (a) The client who had a stroke 4 days ago with left sided weakness who needs feeding (b) The client who needs a Fleet enema administered prior to colonoscopy (c) A recently admitted client who needs their vital signs taken (d) A client who requires chest physiotherapy every shift 111. The nursing team consists of a RN/LPN and UAP. Which action should be appropriately assigned to the LPN? * (a) Bathing a child admitted with chickenpox (b) Taking the vital signs of the recently admitted client (c) Transporting a client to the chapel for noon time prayers (d) Insertion of an indwelling catheter for a client with urinary retention 112. In providing care for a client being treated for fl uid volume excess, which of the following interventions would be best delegated to an experienced UAP? Select all that apply.* (a) Monitor EKG readings (b) Obtain vital signs every 30 minutes (c) Check for the presence of pedal edema (d) Insert IV line (e) Document hourly urine output (f) Measure weight 113. A mental health nurse is fl oated to work on the medical surgical unit. Which client would be most appropriate to assign to the mental health nurse? A client that: (a) is 4 hours post operative following cholecystectomy (b) has dehydration and needs IV fl uids (c) has mechanical ventilation and needs to be suctioned (d) is in traction for a broken femur 114. A nurse is caring for the following clients. Which client is the priority to be assigned to a private room? A client with (a) HIV (b) Cirrhosis of the liver (c) Scabies (d) Pneumonia 115. A nurse is caring for the following clients. Which client is a priority to be assigned to a private room? A client with (a) Rubeola (b) Rubella (c) Klebsiella Pneumoniae (d) Pediculosis 116. The nurse is caring for several clients requiring isolation. There is one private room available on the unit. The nurse should place the highest priority on assigning which of the following clients to the private room? The client (a) with fever and diarrhea for 2 days after taking antibiotics (b) who is HIV + with a temperature of 101° (c) with low grade fever and night sweats (d) with Leukemia whose temperature is 100° 117. The infection control nurse is making rounds on a Medical Surgical unit. Which of the following, if observed by the nurse requires immediate intervention? (a) A UAP is observed wearing gloves while emptying a urine drainage bag (b) An RN is observed wearing a surgical face mask while caring for a client with tuberculosis (TB) in a negative pressure room (c) An LPN is observed wearing a gown and gloves while caring for a mentally ill client with Clostridium Diffi cile toxin (d) A RN is observed wearing a gown, gloves, and shoe covers while caring for a client with Ebola Virus 118. The nurse should initiate protective precautions for the client who has (a) Red Blood Cell Count (RBC) of 3,900/mm3 (b) Platelet count of 400,000µ/L (c) Hemoglobin (Hgb) 9.0 g/dl (d) White Blood Cell Count (WBC) 2,500/mm3 119. A nurse is caring for a client experiencing late decelerations. The appropriate initial action by the nurse is to: (a) change the clients position (b) notify the health care provider in charge (c) increase the Pitocin (Oxytocin) drip (d) decrease the IV fl uid infusion 120. A nurse working in labor and delivery walks into the room of a client that is 37- weeks-gestation and notices a prolapsed cord? The initial action of the nurse should be to (a) use a sterile glove to put cord back inside (b) place the client in trendelenburg position (c) use a dry sterile gauze to cover the cord (d) initiate Leopold’s Manuever to approximate the fetal position 121. A nurse in the prenatal clinic is caring for a client. The last normal menstrual period was from May 3, 2008 to May 8, 2008. Calculate the expected date of confi nement (EDC). (a) March 15, 2009 (b) January 10, 2009 (c) February 10, 2009 (d) February 15, 2009 122. A nurse working in a clinic is doing teaching regarding sexually transmitted Infections. The client cannot understand how syphillis was contracted because there has been no sexual activity for several days. As part of teaching, the nurse explains that the incubation period for syphilis is about: (a) 1 month (b) 1 week (c) 2 - 3 weeks (d) 2 - 4 months 123. A client is admitted to Labor and Delivery at 38 weeks gestation. The nurse would be correct to state that the client is in the second stage of labor when (a) the placenta is delivered (b) bulging is seen in the perineum (c) contractions are irregular (d) rubra lochia is noted 124. A client on an inpatient psychiatric unit believes the staff is trying to poison her. The nurse should: (a) Explain that the staff is trust-worthy (b) Allow the client see others eat their food (c) Offer factory-sealed foods and beverages (d) Taste the food in front of the client to prove it is edible 125. A nurse is caring for a client taking Thorazine (Chlorpromazine). Which statement shows an understanding of instructions regarding this medication? The client states (a) “I will take my pills every time I hear voices” (b) “I will drink extra fl uid to prevent this dry mouth “ (c) “ I will wear a wide brim hat up at the beach” (d) “ I will stop my medication when I feel better” 126. An emergency room nurse is caring for a client with suspected phenobarbitol use. Which of the following will result if the client has a barbituate addiction? (a) Watery eyes, slow shallow breathing, frequent sniffi ng (b) Dilated pupils, shallow respirations, weak and rapid pulse (c) Constricted pupils, respirations depressed, nausea, vomiting (d) Sluggish pupils, increased respirations, decreased pulse 127. The nurse has attended a staff development conference on cultural considerations for client’s receiving hospice care. Which of the following statements if made by the nurse would require follow up? (a) The family of a client of Buddhist faith may ask for a priest to be present at the time of death (b) The family of a client of Jewish faith may request to have mirrors covered after the death of the client (c) The family of a client of Muslim faith may request that the body of the client be turned to face the south east at the time of the client’s death (d) The family of a client of Hindu faith may request that the body be bathed after their death 128. A nurse is caring for a client admitted with Laënnec’s cirrhosis. Which vitamin supplement may be necessary to include? (a) Vitamin B6 (b) Vitamin A (c) Vitamin B1 (d) Vitamin C 129. A nurse is caring for a client with Celiac disease. Which of the following statements shows that teaching has been effective? (a) “I enjoy eating oatmeal for breakfast.” (b) “I dislike rice so it will be easy to avoid.” (c) “I will have popcorn and juice while I am at the movies.” (d) “I can have eggs with my rye toast.” 130. The nurse is observing a client with renal failure select foods from the lunch menu. Which of the following selections if made by the client would indicate a need for further teaching? (a) Haddock and spaghetti (b) Cereal with buttermilk (c) Corned beef and rice (d) Orange juice with wheat toast 131. The nurse knows that the plan of care for a client with severe Ulcerative Colitis would include which of the following? (a) Low protein, high carbohydrate diet (b) Low residue, high protein (c) High protein, high residue (d) High carbohydrate, high protein 132. The nurse is attempting to collect a stool sample for occult blood. Which of the following foods should the client avoid prior to the test? (a) Oranges (b) Watermelon (c) Bananas (d) Kiwi 133. A client is performing quadriceps sets to strengthen the muscles used for walking. When performing these exercises, the client contracts his quadriceps with no change in muscle length and no joint movement. What term does the nurse use to describe this type of exercise? 134. A nurse is teaching a client to ambulate with crutches. The crutch gait the nurse should teach a client after a single leg amputation is the: (a) two point gait (b) three point gait (c) four point gait (d) swing through gait 135. A nurse is preparing to give a dose of Bumex IV to an infant. The prescription reads give 1mg/kg daily. If the infant weighed 6lbs, how many mg should the infant receive? mg 136. An IV of Ringer’s Lactate 1,000 ml is to infuse over 8 hours. The drop factor is 15gtt/ml. Calculate the rate of fl ow. gtt(s)/min 137. A client is to receive Dopamine (Intropin) 3 mcg/kg/min. The client weighs 185 pounds. The available dose is 400 mg per 500 ml D5NS. How many milliliters should be administered each hour? (Round to the nearest tenth) * ml 138. A physician has selected a medication for a client with glaucoma that is to be administered one time per week. Which of the following medications is a direct acting parasympathomimetic agent used as a miotic in the treatment of glaucoma? (a) humorsol (demecarium) (b) cyclogyl (cyclopentolate) (c) pilocarpine (pilocar) (d) timolol (timoptic) 139. The nurse is caring for a client taking the medication Clozaril (Clozapine). Which of the following statements if made by the client shows that teaching has been effective? (a) “I will increase my glucose intake.” (b) “I should include bulk and fl uids in my diet.” (c) “I should expect a decrease in my risk of infection.” (d) “I must remember that hypertension is common.” 140. A student nurse is preparing to administer Cardura (Doxazosin). Which of the following should be included in teaching? Select all that apply. (a) avoid driving (b) expect increased libido (c) double doses if one dose is missed (d) continue to take cold remedies (e) blurred vision may occur 141. The parent of a child taking Concerta (Methylphenidate) calls the clinic and reports the following symptoms. The nurse knows which of the following is an expected side effect? (a) lethargy (b) increased appetite (c) weight gain (d) metallic taste in the mouth 142. The nurse is caring for a 76 year old client whose past medical history includes coronary artery disease. A review of the laboratory results reveal: HDL 34, LDL 168 and total Cholesterol 270. Which of the following medications might be included in the plan of care? (a) Tagamet (Cimetidine) 300 mg po four times a day (b) Coumadin (Warfarin Sodium) 2 mg po at bedtime (c) Questran (Choleystyramine) 4 gms po every day (d) Reglan (Metoclopramide) 10mg po as needed 143. A nurse is caring for a client who is complaining of muscle spasms and rigidity. It would be a priority for the nurse to check which lab value? (a) K+ (b) NA+ (c) Ca+ (d) Mg- 144. A nurse is caring for a client with Multiple Myeloma. The nurse would expect abnormalities in which of the following lab values? (a) ammonia (b) red blood cells (c) glucose (d) potassium 145. A nurse is using the Glasgow coma scale to assess a client who had a head injury. During assessment, the following is observed: Eyes open to speech, motor response appropriate, client obeys commands, and conversation is confused. The client should receive a score of: (a) 3-5 (b) 6-10 (c) 11-13 (d) 14-15 146. The nurse is caring for a client who underwent surgical repair of a detached retina of the right eye. Which of the following interventions should the nurse perform? Select all that apply. (a) place the client in the prone position (b) approach the client from the left side (c) encourage deep breathing and coughing (d) discourage bending at the waist (e) orient the client to his environment (f) administer a stool softener as prescribed 147. The nurse is caring for a client with hypothyroidism. Expected fi ndings for this disorder include: Select all that apply. (a) Constipation (b) Dry skin (c) Anorexia (d) Insomnia (e) Bradycardia (f) Palpitations 148. While doing a routine check up with the gynecologist, a 32 year old client complains of frequent yeast infections. The nurse knows which of the following may be noted? (a) a fasting glucose of 132 mg/dl (b) a white blood count of 10,000 cc mm (c) a HGB (hemoglobin) of 15 mg/dl (d) a BUN (blood urea nitrogen) of 19 mg/dl 149. A nurse is providing care for a client with Type I IDDM complaining of a headache. What should the nurse do fi rst? (a) Give one cup of orange juice (b) Call the nurse in charge (c) Check the clients glucose level (d) Administer insulin as prescribed 150. The charge nurse was alerted about the need for multiple admissions following a tornado. Which of the following client’s would be appropriate for the charge nurse to recommend for discharge? * (a) A client with a T3 injury reporting headache (b) A client with a chest tube that has continuous bubbling in the water seal chamber (c) The bipolar client with a Lithium level of 1.8 mEq/L (d) The COPD client with an ABG reading of pH 7.34 PaO2 89 PaCO2 55 HCO3 23 Bonus Questions ( Hot Spot ) 1. The nurse is assessing a client’s pulses after a cardiac catheterization using the femoral artery. In addition to the posterior tibial pulse place an X on the other pulse site that should be assessed. 2. A child presents to the clinic with fever, lethargy, nausea, and vomiting, and erythema. Erythema Infectiosum (Fifth Disease) is suspected. Place an X where the nurse would expect the initial rash to appear. 3. The nurse is preparing to administer an intramuscular injection to an infant. Identify the area that the injection should be administered. 4. A nurse is interpreting a rhythm on the cardiac monitor. Identify the area which represents atrial depolarization. 5. A nurse has assessed an unresponsive adult victim and noted absence of breathing and circulation. Indicate where the self adhesive electrode pads should be placed in preparation for automated external defi brillation. 6. A nurse is preparing to administer an injection. Identify the area known as the dorsogluteal site for intramuscular injections. 7. Use an X to identify the area of the lungs where the chest X-ray is likely to reveal infi ltrates in a client diagnosed with tuberculosis (TB). Rationales 1. A. The normal potassium level is 3.5 – 5.0 mEq/L. Giving Kayexalate in this situation may cause the client to lose potassium, causing hypokalemia, therefore the drug is not indicated; the therapeutic level for Dilantin is 10 – 20 mcg/ml, a level of 8 is sub therapeutic thereby increasing the risk of seizure activity. Acetaminophen can be safely prescribed to clients with ASA sensitivity. Azithromycin (Zithromax) can be safely prescribed for clients with sensitivity to Penicillin. Safe Effective Care Environment; Management of Care 2. A. Informed consent, explanation and decision making must occur before sedation is given; therapeutic interventions for retinal detachment include bedrest with the area of detachment in a dependent position to promote healing; the cast should be handled with the palms of the hands while wet to prevent denting; a broad base of support is used during transfers to prevent muscle injury. Safe Effective Care Environment; Management of Care 3. B. An adolescent with uncontrolled Diabetes Mellitus would require the greatest number of disciplines (multidisciplinary) to manage their care i.e. Medicine, Nursing, Social Work, Nutritionist; the other choices do not require as many providers of care to meet their needs. Safe Effective Care Environment; Management of Care 4. C. The management of a client following abdominal surgery is standard. The postpartum nurse routinely cares for mothers following caesarean section; therefore it is appropriate to assign this client; The other choices are not appropriate to assign to this nurse. Safe Effective Care Environment; Management of Care 5. D. A child experiencing normal growth and development should be ambulating independently by 12 months; the Babinski refl ex disappears after 2 years of age; an infant typically holds their own bottle by 6 months; stranger anxiety usually develops at approximately 7 months. Safe Effective Care Environment; Management of Care 6. C. Consent for organ donation is given by a client’s next of kin in the absence of an Advance Directive. Safe Effective Care Environment; Management of Care 7. C. The client admitted with Guillain-Barre’ Syndrome should be assessed fi rst because of the possibility of rapid progression of this illness and neuromuscular respiratory failure; clients with COPD are likely to have pulse oximetry readings of 90% related to chronic hypoxia; this client along with the other two choices are important, but not the priority. Safe Effective Care Environment; Management of Care 8. B. The Certifi ed Nursing Assistant may be assigned to a client that requires one- to-one observation for safety; the other choices require skilled nursing intervention by a LPN (Licensed Practical Nurse) or RN (Registered Nurse). Safe Effective Care Environment; Management of Care 9. A. To maintain confi dentiality the nurse should not discuss the client’s diagnosis with family members; it is advisable that two nurses review the prescription for blood transfusion to identify the client, blood type, Rh factor, expiration date and the blood numbers; interrupting staff members discussing a client in a public place should be done to maintain client confi dentiality; collaborating with the nutritionist is an appropriate nursing intervention. Safe Effective Care Environment; Management of Care 10. A. Putting a client in a geriatric chair with the lap tray in front of them restricts movement which constitutes false imprisonment; choice B is an example of assault not battery; C is an example of negligence not malpractice and D is an example of battery not assault. Safe Effective Care Environment; Management of Care 11. C. Vomiting and diarrhea can be managed on a non-emergent basis; clients reporting “indigestion” may be experiencing a cardiac event; clinical manifestations suggestive of abdominal aortic aneurysm include abdominal mass and abdominal throbbing; the client who is 6 weeks pregnant experiencing abdominal pain must be evaluated to rule out ectopic pregnancy which could be life threatening. Safe Effective Care environment; Management of Care 12. D. Following cardiac catheterization using the femoral artery, the client remains on bedrest for 2 to 6 hours with the affe