RN Exit v2 test ****A+ HESI MED SURG REAL EXIT
EXAM WITH NGN UPDATED LATEST SOLUTIONS
The nurse assumes care of a postoperative adult client with type 2 diabetes
mellitus and learns that the client has a current blood glucose level of 720 mg/dL.
When assessing the client, what is the priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate
A. Assess for signs of fluid volume deficit
A male client tells the nurse that he is concerned that he may have a stomach
ulcer, because he is experiencing heartburn and dull gnawing pain that is relieved
when he eats. Which is the best response by the nurse?
A. Encourage the client to obtain a complete physical exam, since these
symptoms are consistent with an ulcer
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is
not relieved with food
C. Instruct the client that these mild symptoms can generally be controlled with
changes in his diet
D. Advise the client that he needs to seek immediate medical evaluation and
treatment of these symptoms
A. Encourage the client to obtain a complete physical exam, since these symptoms are
consistent with an ulcer
A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a nasogastric tube to suction and is receiving Lactated
Ringer's solution at 75 mL/hr IV. One hour after admission to the unit, the nurse
notes 300mL of blood in the suction canister, the client's heart rate is 155
beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the
findings to the surgeon, which action should the nurse implement first?
A. Measure and document the client's urinary output
B. Request the client's reserved unit of packed red blood cells
C. Prepare for placement of a central venous catheter
D. Increase the infusion rate of Lactated Ringer's solution
D. Increase the infusion rate of Lactated Ringer's solution
A heparin infusion is prescribed for a client who weighs 220 pounds. After
administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate
for the heparin solution as 18 units/kg/hour. The available solution is Heparin
Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program
the infusion pump to deliver how many mL/hour?
-1st: calculate the weight = 220/2.2= 100kg
-Then calculate total dose in units = 18units x 100kg = 1800 units/hr
- 25000 units - in 250
,1800 units ---in X ml
x = 1800 x 250/25000 =18 mL/hr
An adult male who fell 20 feet from the roof of his home has multiple injuries,
including a right pneumothorax. Chest tubes were inserted in the emergency
department prior to his transfer to the intensive care unit (ICU). The nurse notes
that the suction control chamber is bubbling at the -10cm H2O mark, which
fluctuation in the water seal, and over the past hour 75 mL of bright red blood is
measured in the collection chamber. Which intervention should the nurse
implement?
A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
C. Manipulate blood in tubing to drain into chamber
D. Increase wall suction to eliminate fluctuation in water seal
A. Add sterile water to the suction control chamber
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife
approaches the nurse and asks how she will know that her husband's death is
imminent because their two adult children want to be there when he dies. Which
is the best response by the nurse?
A. Gather information regarding how long it will take for the children to arrive
B. Explain that the client will start to lose consciousness and the body systems
will slow down
C. Reassure the spouse that the healthcare provider will notify when to call the
children
D. Offer to discuss the client's health status with each of the adult children
B. Explain that the client will start to lose consciousness and the body systems will slow
down
The charge nurse of a critical care unit is informed at the beginning of the shift
that less than the optimal number of registered nurses will be working that shift.
In planning assignments, which client should receive the most care hours by a
registered nurse (RN)?
A. A 48-year-old marathon runner with a central venous catheter who is
experiencing nausea and vomiting due to electrolyte disturbance following a race
B. A 34-year-old admitted today after an emergency appendectomy who has a
peripheral intravenous catheter and a Foley catheter
C. A 63-year-old chain smoker admitted with chronic bronchitis who is receiving
oxygen via nasal cannula and has a saline-locked peripheral intravenous catheter
D. An 82-year-old client with Alzheimer's disease and a newly-fractured femur
who has a Foley catheter and soft wrist restraints applied
D. An 82-year-old client with Alzheimer's disease and a newly-fractured femur who has
a Foley catheter and soft wrist restraints applied
The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled
"750 mcg/2.4mL". How many mL should the nurse administer? Round to nearest
tenth.
0.2 mL
In caring for a client with Cushing's Syndrome, which serum laboratory value is
most important for the nurse to monitor?
,A. Creatinine
B. Lactate
C. Glucose
D. Hemoglobin
C. Glucose
A client who received hemodialysis yesterday is experiencing a blood pressure of
200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36
breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal
edema, and an oxygen saturation on room air of 89%. Which action should the
nurse take first?
A. Elevate the foot of the bed
B. Restrict the client's fluids
C. Begin supplemental oxygen
D. Prepare client for hemodialysis
C. Begin supplemental oxygen
When caring for a client with full thickness burns to both lower extremities, which
assessment findings warrant immediate intervention? Select all that apply
A. Sloughing tissue around wound edges
B. Complaint of increased pain and pressure
C. Change in the quality of the peripheral pulses
D. Loss of sensation to the left lower extremity
E. Weeping serosanguineous fluid from wounds
B. Complaint of increased pain and pressure
C. Change in the quality of the peripheral pulses
D. Loss of sensation to the left lower extremity
An older client is admitted with fluid volume deficit and dehydration. Which
assessment finding is the best indicator of hydration that the nurse should report
to the healthcare provider?
A. Urine specific gravity is 1.040
B. Systolic blood pressure decreases 10 points when standing
C. The client denies being thirsty
D. Skin tenting occurs when the client's forearm is pinched
D. Skin tenting occurs when the client's forearm is pinched
The healthcare provider prescribes methylergonovine maleate for a postpartum
client with uterine atony. What finding should indicate to the nurse to withhold
the next dose of the medication?
A. Difficulty locating the uterine fundus
B. Excessive lochia
C. Saturation of more than one pad per hour
D. Hypertension
D. Hypertension
After an inservice about electronic health record (EHR) security and safeguarding
client information, the nurse observes a colleague going home with printed
copies of client information in a uniform pocket. Which action should the nurse
take?
A. File a detailed incident report with the specific hiring facility
, B. Warn the colleague that their actions are unprofessional
C. Comment anonymously about the action on a staff discussion board
D. Communicate the colleague's actions to the unit charge nurse
A. File a detailed incident report with the specific hiring facility
The nurse is evaluating a tertiary prevention program for clients with
cardiovascular disease implemented in a rural health clinic. Which outcome
indicates the program is effective?
A. At-risk clients received an increased number of routine health screenings
B. Clients reported having new confidence in making healthy food choices
C. Clients who incurred disease complications promptly received rehabilitation
D. Client relapse of 30% in a 5-year community-wide anti-smoking campaign
C. Clients who incurred disease complications promptly received rehabilitation
While caring for a client's postoperative dressing, the nurse observes purulent
drainage at the wound. Before reporting this finding to the healthcare provider,
the nurse should review which of the client's laboratory values?
A. Culture for sensitive organisms
B. Serum blood glucose (BG) level
C. Creatinine level
D. Serum albumin
A. Culture for sensitive organisms
A client is admitted with acute pancreatitis. The client admits to drinking a pint of
bourbon daily. The nurse medicates the client for pain and monitors vital signs
every 2 hours. Which finding should the nurse report immediately to the
healthcare provider?
A. Anorexia and abdominal distention
B. Abdominal pain and vomiting
C. Confusion and tremors
D. Yellowing and itching of skin
C. Confusion and tremors
A client with leukemia who is receiving a myleosuppressive chemotherapy has a
platelet count of 25,000/mm3. Which intervention is most important for the nurse
to include in this client's plan of care?
A. Assess urine and stool for occult blood
B. Monitor for signs of activity intolerance
C. Require visitors to wear respiratory masks
D. Obtain client's temperature q4 hours
A. Assess urine and stool for occult blood
When assessing a 6-month-old infant, the nurse determines that the anterior
fontanel is bulging. In which situation would this findings be most significant?
A. Crying
B. Sitting upright
C. Vomiting
D. Straining on stool
B. Sitting upright
A client who is admitted to the intensive care unit with syndrome of inappropriate
antidiuretic hormone (SIADH) has developed osmotic demyelination. Which
EXAM WITH NGN UPDATED LATEST SOLUTIONS
The nurse assumes care of a postoperative adult client with type 2 diabetes
mellitus and learns that the client has a current blood glucose level of 720 mg/dL.
When assessing the client, what is the priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate
A. Assess for signs of fluid volume deficit
A male client tells the nurse that he is concerned that he may have a stomach
ulcer, because he is experiencing heartburn and dull gnawing pain that is relieved
when he eats. Which is the best response by the nurse?
A. Encourage the client to obtain a complete physical exam, since these
symptoms are consistent with an ulcer
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is
not relieved with food
C. Instruct the client that these mild symptoms can generally be controlled with
changes in his diet
D. Advise the client that he needs to seek immediate medical evaluation and
treatment of these symptoms
A. Encourage the client to obtain a complete physical exam, since these symptoms are
consistent with an ulcer
A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a nasogastric tube to suction and is receiving Lactated
Ringer's solution at 75 mL/hr IV. One hour after admission to the unit, the nurse
notes 300mL of blood in the suction canister, the client's heart rate is 155
beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the
findings to the surgeon, which action should the nurse implement first?
A. Measure and document the client's urinary output
B. Request the client's reserved unit of packed red blood cells
C. Prepare for placement of a central venous catheter
D. Increase the infusion rate of Lactated Ringer's solution
D. Increase the infusion rate of Lactated Ringer's solution
A heparin infusion is prescribed for a client who weighs 220 pounds. After
administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate
for the heparin solution as 18 units/kg/hour. The available solution is Heparin
Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program
the infusion pump to deliver how many mL/hour?
-1st: calculate the weight = 220/2.2= 100kg
-Then calculate total dose in units = 18units x 100kg = 1800 units/hr
- 25000 units - in 250
,1800 units ---in X ml
x = 1800 x 250/25000 =18 mL/hr
An adult male who fell 20 feet from the roof of his home has multiple injuries,
including a right pneumothorax. Chest tubes were inserted in the emergency
department prior to his transfer to the intensive care unit (ICU). The nurse notes
that the suction control chamber is bubbling at the -10cm H2O mark, which
fluctuation in the water seal, and over the past hour 75 mL of bright red blood is
measured in the collection chamber. Which intervention should the nurse
implement?
A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
C. Manipulate blood in tubing to drain into chamber
D. Increase wall suction to eliminate fluctuation in water seal
A. Add sterile water to the suction control chamber
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife
approaches the nurse and asks how she will know that her husband's death is
imminent because their two adult children want to be there when he dies. Which
is the best response by the nurse?
A. Gather information regarding how long it will take for the children to arrive
B. Explain that the client will start to lose consciousness and the body systems
will slow down
C. Reassure the spouse that the healthcare provider will notify when to call the
children
D. Offer to discuss the client's health status with each of the adult children
B. Explain that the client will start to lose consciousness and the body systems will slow
down
The charge nurse of a critical care unit is informed at the beginning of the shift
that less than the optimal number of registered nurses will be working that shift.
In planning assignments, which client should receive the most care hours by a
registered nurse (RN)?
A. A 48-year-old marathon runner with a central venous catheter who is
experiencing nausea and vomiting due to electrolyte disturbance following a race
B. A 34-year-old admitted today after an emergency appendectomy who has a
peripheral intravenous catheter and a Foley catheter
C. A 63-year-old chain smoker admitted with chronic bronchitis who is receiving
oxygen via nasal cannula and has a saline-locked peripheral intravenous catheter
D. An 82-year-old client with Alzheimer's disease and a newly-fractured femur
who has a Foley catheter and soft wrist restraints applied
D. An 82-year-old client with Alzheimer's disease and a newly-fractured femur who has
a Foley catheter and soft wrist restraints applied
The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled
"750 mcg/2.4mL". How many mL should the nurse administer? Round to nearest
tenth.
0.2 mL
In caring for a client with Cushing's Syndrome, which serum laboratory value is
most important for the nurse to monitor?
,A. Creatinine
B. Lactate
C. Glucose
D. Hemoglobin
C. Glucose
A client who received hemodialysis yesterday is experiencing a blood pressure of
200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36
breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal
edema, and an oxygen saturation on room air of 89%. Which action should the
nurse take first?
A. Elevate the foot of the bed
B. Restrict the client's fluids
C. Begin supplemental oxygen
D. Prepare client for hemodialysis
C. Begin supplemental oxygen
When caring for a client with full thickness burns to both lower extremities, which
assessment findings warrant immediate intervention? Select all that apply
A. Sloughing tissue around wound edges
B. Complaint of increased pain and pressure
C. Change in the quality of the peripheral pulses
D. Loss of sensation to the left lower extremity
E. Weeping serosanguineous fluid from wounds
B. Complaint of increased pain and pressure
C. Change in the quality of the peripheral pulses
D. Loss of sensation to the left lower extremity
An older client is admitted with fluid volume deficit and dehydration. Which
assessment finding is the best indicator of hydration that the nurse should report
to the healthcare provider?
A. Urine specific gravity is 1.040
B. Systolic blood pressure decreases 10 points when standing
C. The client denies being thirsty
D. Skin tenting occurs when the client's forearm is pinched
D. Skin tenting occurs when the client's forearm is pinched
The healthcare provider prescribes methylergonovine maleate for a postpartum
client with uterine atony. What finding should indicate to the nurse to withhold
the next dose of the medication?
A. Difficulty locating the uterine fundus
B. Excessive lochia
C. Saturation of more than one pad per hour
D. Hypertension
D. Hypertension
After an inservice about electronic health record (EHR) security and safeguarding
client information, the nurse observes a colleague going home with printed
copies of client information in a uniform pocket. Which action should the nurse
take?
A. File a detailed incident report with the specific hiring facility
, B. Warn the colleague that their actions are unprofessional
C. Comment anonymously about the action on a staff discussion board
D. Communicate the colleague's actions to the unit charge nurse
A. File a detailed incident report with the specific hiring facility
The nurse is evaluating a tertiary prevention program for clients with
cardiovascular disease implemented in a rural health clinic. Which outcome
indicates the program is effective?
A. At-risk clients received an increased number of routine health screenings
B. Clients reported having new confidence in making healthy food choices
C. Clients who incurred disease complications promptly received rehabilitation
D. Client relapse of 30% in a 5-year community-wide anti-smoking campaign
C. Clients who incurred disease complications promptly received rehabilitation
While caring for a client's postoperative dressing, the nurse observes purulent
drainage at the wound. Before reporting this finding to the healthcare provider,
the nurse should review which of the client's laboratory values?
A. Culture for sensitive organisms
B. Serum blood glucose (BG) level
C. Creatinine level
D. Serum albumin
A. Culture for sensitive organisms
A client is admitted with acute pancreatitis. The client admits to drinking a pint of
bourbon daily. The nurse medicates the client for pain and monitors vital signs
every 2 hours. Which finding should the nurse report immediately to the
healthcare provider?
A. Anorexia and abdominal distention
B. Abdominal pain and vomiting
C. Confusion and tremors
D. Yellowing and itching of skin
C. Confusion and tremors
A client with leukemia who is receiving a myleosuppressive chemotherapy has a
platelet count of 25,000/mm3. Which intervention is most important for the nurse
to include in this client's plan of care?
A. Assess urine and stool for occult blood
B. Monitor for signs of activity intolerance
C. Require visitors to wear respiratory masks
D. Obtain client's temperature q4 hours
A. Assess urine and stool for occult blood
When assessing a 6-month-old infant, the nurse determines that the anterior
fontanel is bulging. In which situation would this findings be most significant?
A. Crying
B. Sitting upright
C. Vomiting
D. Straining on stool
B. Sitting upright
A client who is admitted to the intensive care unit with syndrome of inappropriate
antidiuretic hormone (SIADH) has developed osmotic demyelination. Which
