EXIT V1 Complete Questions and
Answers
Which information is a priority for the RN to reinforce to an older client after intravenous
pylegraphy? - ANS-Measure the urine output for the next day and immediately notify the
health care provider if it should decrease.
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 - ANS-weekly
weight
A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most
important for the nurse to reinforce with the client? - ANS-It is critical to report promptly
to your health care provider any findings of peptic ulcers
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? - ANS-Have the client turn to the left side
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? - ANS-A cold, pale lower leg
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? - ANS-Fever of 103
degrees Fahrenheit (39.5 degrees Celsius)
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? - ANS-Until the health
care provider has determined that your ejaculate doesn't contain
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? - ANS-The flow of life is believed to flow
through major pathways or nerve clusters in your body.
,The nurse is discussing with a group of students the disease Kawasaki. What statement
made by a student about Kawasaki disease is incorrect? - ANS-Kawasaki disease
occurs most often in boys, children younger than age 5 and children of Hispanic
descent
A client has viral pneumonia affecting 2/3 of the right lung. What would be the best
position to teach the client to lie in every other hour during first 12 hours after
admission? - ANS-Side-lying on the left with the head elevated 10 degrees
A client has an indwelling catheter with continuous bladder irrigation after undergoing a
transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time
should be reported to the health care provider? - ANS-minimal drainage into the urinary
collection bag
A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another
nurse enters the room in response to the call. After checking the client's pulse and
respirations, what should be the function of the second nurse? - ANS-Participate with
the compressions or breathing
. 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? - ANS-Jugular
vein distention
A client with heart failure has a prescription for digoxin. The nurse is aware that
sufficient potassium should be included in the diet because hypokalemia in combination
with this medication? - ANS-Can predispose to dysrhythmias
A nurse assesses a young adult in the emergency room following a motor vehicle
accident. Which of the following neurological signs is of most concern? - ANS-Pupils
fixed and dilated
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 - ANS-"I went to the health care provider last week
for a cold and I have gotten worse."
Which these findings would the nurse more closely associate with anemia in a 10
month-old infant? - ANS-Pale mucosa of the eyelids and lips
The nurse is caring for a client in hypertensive crisis in an intensive care unit. The
, priority assessment in the first hour of care is - ANS-Pupil responses
Which of these clients who are all in the terminal stage of cancer is least appropriate to
suggest the use of patient controlled analgesia (PCA) with a pump? - ANS-A
preschooler with intermittent episodes of alertness
The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive
(NOFTT). Upon entering the room, the nurse would expect the baby to be - ANS-Pale,
thin arms and legs, uninterested in surroundings
As the nurse is speaking with a group of teens which of these side effects of
chemotherapy for cancer would the nurse expect this group to be more interested in
during the discussion? - ANS-Hair loss
While caring for a client who was admitted with myocardial infarction (MI) 2 days ago,
the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees
Celsius). The appropriate nursing intervention is to - ANS-Administer acetaminophen as
ordered as this is normal at this time
. A client is admitted for first and second degree burns on the face, neck, anterior chest
and hands. The nurse's priority should be - ANS-Assess for dyspnea or stridor
Which of these clients who call the community health clinic would the nurse ask to come
in that day to be seen by the health care provider? - ANS-I went to the bathroom and my
urine looked very red and it didn't hurt when I went.
A middle aged woman talks to the nurse in the health care provider's office about
uterine fibroids also called leiomyomas or myomas. What statement by the woman
indicates more education is needed? - ANS-Fibroids that cause no problems still need
to be taken out.
An elderly client admitted after a fall begins to seize and loses consciousness. What
action by the nurse is appropriate to do next? - ANS-Stay with client and observe for
airway obstruction
A nurse is providing care to a primigravida whose membranes spontaneously ruptured
(ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were
T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min.
Which assessment findings taken now may be an early indication that the client is
Answers
Which information is a priority for the RN to reinforce to an older client after intravenous
pylegraphy? - ANS-Measure the urine output for the next day and immediately notify the
health care provider if it should decrease.
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 - ANS-weekly
weight
A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most
important for the nurse to reinforce with the client? - ANS-It is critical to report promptly
to your health care provider any findings of peptic ulcers
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? - ANS-Have the client turn to the left side
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? - ANS-A cold, pale lower leg
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? - ANS-Fever of 103
degrees Fahrenheit (39.5 degrees Celsius)
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? - ANS-Until the health
care provider has determined that your ejaculate doesn't contain
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? - ANS-The flow of life is believed to flow
through major pathways or nerve clusters in your body.
,The nurse is discussing with a group of students the disease Kawasaki. What statement
made by a student about Kawasaki disease is incorrect? - ANS-Kawasaki disease
occurs most often in boys, children younger than age 5 and children of Hispanic
descent
A client has viral pneumonia affecting 2/3 of the right lung. What would be the best
position to teach the client to lie in every other hour during first 12 hours after
admission? - ANS-Side-lying on the left with the head elevated 10 degrees
A client has an indwelling catheter with continuous bladder irrigation after undergoing a
transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time
should be reported to the health care provider? - ANS-minimal drainage into the urinary
collection bag
A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another
nurse enters the room in response to the call. After checking the client's pulse and
respirations, what should be the function of the second nurse? - ANS-Participate with
the compressions or breathing
. 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? - ANS-Jugular
vein distention
A client with heart failure has a prescription for digoxin. The nurse is aware that
sufficient potassium should be included in the diet because hypokalemia in combination
with this medication? - ANS-Can predispose to dysrhythmias
A nurse assesses a young adult in the emergency room following a motor vehicle
accident. Which of the following neurological signs is of most concern? - ANS-Pupils
fixed and dilated
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 - ANS-"I went to the health care provider last week
for a cold and I have gotten worse."
Which these findings would the nurse more closely associate with anemia in a 10
month-old infant? - ANS-Pale mucosa of the eyelids and lips
The nurse is caring for a client in hypertensive crisis in an intensive care unit. The
, priority assessment in the first hour of care is - ANS-Pupil responses
Which of these clients who are all in the terminal stage of cancer is least appropriate to
suggest the use of patient controlled analgesia (PCA) with a pump? - ANS-A
preschooler with intermittent episodes of alertness
The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive
(NOFTT). Upon entering the room, the nurse would expect the baby to be - ANS-Pale,
thin arms and legs, uninterested in surroundings
As the nurse is speaking with a group of teens which of these side effects of
chemotherapy for cancer would the nurse expect this group to be more interested in
during the discussion? - ANS-Hair loss
While caring for a client who was admitted with myocardial infarction (MI) 2 days ago,
the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees
Celsius). The appropriate nursing intervention is to - ANS-Administer acetaminophen as
ordered as this is normal at this time
. A client is admitted for first and second degree burns on the face, neck, anterior chest
and hands. The nurse's priority should be - ANS-Assess for dyspnea or stridor
Which of these clients who call the community health clinic would the nurse ask to come
in that day to be seen by the health care provider? - ANS-I went to the bathroom and my
urine looked very red and it didn't hurt when I went.
A middle aged woman talks to the nurse in the health care provider's office about
uterine fibroids also called leiomyomas or myomas. What statement by the woman
indicates more education is needed? - ANS-Fibroids that cause no problems still need
to be taken out.
An elderly client admitted after a fall begins to seize and loses consciousness. What
action by the nurse is appropriate to do next? - ANS-Stay with client and observe for
airway obstruction
A nurse is providing care to a primigravida whose membranes spontaneously ruptured
(ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were
T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min.
Which assessment findings taken now may be an early indication that the client is
