2016 Hesi Version 4

1. A male client who had a transurethral resection of the prostate (TURP) today has
a continuous bladder irrigation (CBI). The client requests pain medication for
abdominal pain rated at 9 on a scale of 1 to 10. What action should the nurse
take first?
A. Administer prescribed PRN analgesic medication.
B. Position him on the left side and slow the irrigation rate.
C. Palpate his abdomen and check his urinary output. <
D. Assist him to ambulate to help pass flatus.

2. The mental health nurse takes several adolescent clients to the inpatient
schoolroom. The teacher asks the nurse to stay and help one of the male clients
who has attention-deficit hyperactivity disorder with his spelling assignment.
Which goal is reasonable for this client to attain during this one-hour class?
A. Completes at least one page of spelling. <
B. Follows directions the first time they are given.
C. Sits quietly with peers and completes assignment.
D. Shares his problems with others in the class.

3. A client is receiving a standardized solution of heparin 25,000-units/250 ml of

normal saline. The healthcare provider prescribes to increase the clients current
infusion rate of heparin to 700 units/hour. How many ml/hour should the nurse
program the infusion pump? Enter the numerical value only.

Using formula, D/H x Q, 700 units/hour 25,000 units x 25o ml = 7 ml/hour

4. A client is receiving the intravenous adrenergic agonist dobutamine (Dobutrex). In

evaluating the clients reaction to the medication, which assessment finding
indicates to the nurse that the medication is effective?
A. The client denies chest pain or discomfort.
B. The client had 160 ml urine output in 8 hours.
C. The clients blood pressure is 110/70 mmHg. <
D. The clients posterior tibial pulses are 1+.

5. A client misses breakfast because of a two-hour hand washing ritual that is

performed daily. What plan is most therapeutic for the nurse to implement?
A. Meet with the client daily to discuss motivation for initiating the ritual.
B. Wake the client early so the ritual can be completed before breakfast. <
C. Set limits on amount of time the client is allowed to perform the ritual.
D. Socialize with the client during the ritual to demonstrate acceptance.

6. Which discharge instruction should the nurse provide a client with heart failure
who is taking digoxin (Lanoxin)?
A. Avoid concurrent use of herbal products. <
B. Take Lanoxin with high-fiber foods.
C. Restrict fluid intake to equal urine output.
 D. Check blood glucose level weekly.

7. The charge nurse in the Intensive Care Unit (ICU) needs to transfer a client to the
medical unit so that a client from the Emergency Room can be admitted to ICU.
Which client is best to consider?
A. A 38-year-old with a myocardial infarction who is having multifocal
premature ventricular contractions.
B. A 66-year-old with congestive heart failure who has 2+ pitting edema and is
short of breath on exertion. <
C. A 58-year-old diagnosed with Guillain-Barre syndrome who is having
difficulty breathing.
D. An 80-year-old with a bleeding peptic ulcer who has a Hgb of 7 g/dl and
coffee ground drainage from NG.

8. The nurse stops to render aid at the scene of a motor vehicle collision and finds a
child about 6 months of age strapped into a car seat in the back seat of the car.
After calming the infant with a pacifier, what action should the nurse take?
A. Remove the infant from the car seat while stabilizing the neck.
B. Assess the infants ability to move arms and legs.
C. Determine if pupils constrict when exposed to light.
D. Lift the car seat out of the car with the infant strapped in it. <

9. An unresponsive female victim of a motor vehicle collision is brought to the

emergency department where it is determined that immediate surgery is required
to save her life. The client is accompanied by a close friend, but no family
members are available. Which intervention should the nurse implement?
A. Obtain an emergency court order for life-saving surgery for the client.
B. Prepare the client for surgery without a signed informed consent. <
C. Ask the womans friend if the client has an advanced directive.
D. Monitor the client until a family member can be located.

10. A confused and combative male client was placed in bilateral wrist restraints to
keep him from pulling out a nasogastric tube. The client developed severe
abrasions on both wrists. On the morning that the abrasions were found, the
clients record contained nursing documentation stating that skin and circulation
checks were conducted every 6 to 8 hours. How should the nurse-manager
respond to this situation?
A. Meet with the clients nurse to determine why adequate assessment was not
performed. <
B. Reassure the staff that skin damage can occur even when the standard of care
is met.
C. Provide an in-service on the documentation needed for clients with altered
skin integrity.
D. Instruct the staff about the correct protocol for the application of bilateral
wrist restraints.
11. When the nurse auscultates the anterior chest just above the right nipple, moderate
pitched breath sounds are heard that are equal on inspiration and expiration.
Which statement best describes this finding?
A. Bronchial breath sounds that are normal in that location.
B. Bronchovesicular breath sounds that are abnormal in that location.
C. Bronchial breath sounds that are abnormal in that location.
D. Bronchovesicular breath sounds that are normal in that location. <

12. A client is seen in the clinic with an acute episode of acute gastritis. Which
nursing diagnosis has the highest priority?
A. Acute pain related to inflammation. <
B. Nausea related to gastric irritation.
C. Knowledge deficit related to diet.
D. Potential for injury related to bleeding.

13. The nurse should encourage males over the age of 45 to obtain which test to
screen for prostatic cancer?
A. Prostate-specific antigen (PSA). <
B. Serum testosterone level.
C. Alpha-fetoprotein radioimmunoassay (AFP).
D. Ultrasound of the scrotum.

14. A male client tells the nurse that he does not want to receive a blood transfusion
that was prescribed to treat internal hemorrhaging. What action should the nurse
implement?
A. Notify the prescribing healthcare provider of the clients refusal to receive the
blood transfusion. <
B. Notify the hospitals attorney of the clients wishes and the need to exercise
life-saving measures.
C. Check the clients medical record to see if he signed a legal informed consent
form.
D. Explain the treatment options available to him if he refuses the prescribed
blood transfusion.

15. The nurse is caring for a laboring client whose membranes ruptured 24 hours
prior to admission. Based on the laboring clients record and the current fetal
monitor reading, which action should the nurse implement? (Click on each chart
for additional information. Please be sure to scroll to the bottom right corner of
each tab to view all information contained in the clients medical record.)
A. Stop the oxytocin infusion.
B. Prepare for Cesarean delivery. <
C. Assess the vital signs.
D. Apply oxygen 10 L/mask.
16. Which nursing intervention has the highest priority when completing discharge
teaching for a client with Helicobacter pylori (H. pylori) induced peptic ulcer
diseases (PUD)?
A. Refer the client to a counselor for information on stress reduction and
relaxation.
B. Encourage the client to eat regularly scheduled meals to help prevent the pain.
C. Instruct the client to take all the antibiotics, proton pump inhibitors, and
Pepto-Bismol. <
D. Teach the importance of taking the Carafate medication immediately before
meals.

17. A client had a total hip replacement two days ago. She has never been in the
hospital before. She has just called for the bedpan. How should the nurse place the
pan under this client?
A. Ask her to roll to the unoperated side and slide the bedpan under her, then roll
back onto the pan. <
B. Ask her to roll to the operated side and slide the bedpan under her, then roll
her back onto the pan.
C. Ask her to flex her knees, spread her legs, and lift her buttocks with the flat
part of her feet, then push the bedpan under her from the front.
D. Ask her to grab her over bed trapeze, push both heels into the mattress, and
raise her buttocks off the bed so the bedpan can be slipped under her.

18. A male client diagnosed with hypertension has a nursing goal of, The client will
be able to verbalize ways to decrease blood pressure. What statement by the
client indicates that this outcome has been met?
A. I should have my blood pressure checked monthly to make sure it is within
normal limits.
B. If I lose weight, quit smoking, and exercise regularly I may not have to take
any medication. <
C. I should increase my fluid intake and decrease my fiber intake.
D. If I take my medication every day, I wont have to worry about my blood
pressure.

19. On the third day of hospitalization for depression, a male client tells the nurse that
he is feeling much better and reports that he believes the antidepressant therapy is
working. He participates in all scheduled activities and agrees to take on
additional ward assignments. What nursing action is most important for the nurse
to implement at this time?
A. Assign an attendant to monitor the clients whereabouts at all times. <
B. Praise the clients willingness to take on additional duties.
C. Encourage the client to share his positive attitude with other clients.
D. Monitor the clients behavior and intake during meals to determine appetite.

20. A client experiencing intracranial hypertension from a traumatic brain injury is

admitted to the trauma unit. How should the nurse position this client?
 A. Totally prone.
B. Right side lying.
C. Completely supine.
D. Elevated head of bed. <

21. The parents of a 4-week-old male infant report that he eats well but vomits after
each feeding. Which assessment finding should the nurse expect him to exhibit if
the baby is receiving inadequate nutrition?
A. Tachypnea.
B. Hypoactive bowel sounds.
C. Sunken fontanels. <
D. Absent Moro reflex.

22. The nurse is planning the discharge teaching for a female client who has frequent
urinary tract infections. In teaching the client how to prevent urinary tract
infections, which recommendation should the nurse include?
A. Void immediately after intercourse. <
B. Sit in a tub of warm water each evening.
C. Drink a glass of water upon arising each morning.
D. Perform Kegel exercises several times daily.

23. When administering an antibiotic that causes photosensitivity, which instruction is

important for the nurse to provide the client?
A. Have hearing checked periodically.
B. Be sure to drink plenty of fluids after activity.
C. Wear long-sleeved clothing outdoors. <
D. Get up slowly to avoid dizziness.

24. A client is receiving an infusion of 500 ml D5W with 25,000 units of heparin at
1,000 units/hour has a partial thromboplastin time (PTT) of 110 seconds. The
sliding scale prescription reads: If the PTT is less than 65 seconds, increase the
rate by 200 units/hour; and if the PTT is greater than 95 seconds decrease the rate
by 200 units/hour. The nurse should regulate the infusion pump for how many
ml/hour? (Enter numeric value only.) 16

25. The nurse teaching a preconception preparation class is discussing ways to

improve dietary folic acid intake. Which evening snack contains the most folic
acid?
A. Whole grain cereal and milk. <
B. Hard-boiled egg and juice.
C. Vanilla milkshake with protein supplement.
D. Toasted white bread with butter.
26. An 8-month-old boy who has tetralogy of Fallot experiences periodic tet spells
with paroxysmal dyspnea. Which nursing intervention is most effective in
managing these episodes?
A. Administer digoxin and Lasix as prescribed.
B. Administer oxygen and place the child in the knee-chest position. <
C. Place the child in a prone position and administer chloral hydrate.
D. Elevate the head of the bed and take the childs vital signs.

27. A 21-year-old male client has developed splenomegaly secondary to infection

mononucleosis. What factor in the clients history is most important in developing
his discharge-teaching plan?
A. He regularly eats at fast food restaurants.
B. On weekends he usually drinks 1 or 2 beers.
C. Lately he has been sleeping 10 to 12 hours every night.
D. He works as a furniture mover. <

28. The nurse is monitoring an infant with pulmonic stenosis. Which finding is most
important for the nurse to report to the healthcare provider?
A. Clubbing of the fingers.
B. Systemic cyanosis. <
C. Presence of a thrill.
D. Polycythemia.

29. The nurse is planning care for a newborn with bladder exstrophy. During the
preoperative period, which intervention should the nurse implement?
A. Expose the bladder to room air to promote scar formation.
B. Place a dry sterile dressing over the exposed bladder.
C. Apply a sterile non-adherent dressing over the bladder. <
D. Use pre-weighed large diapers for diapering the infant.

30. After positioning a client on the side to administer a rectal suppository, the nurse
observes that the client has been incontinent of a large amount of liquid stool,
which has soaked through a gauze pad covering a stage three-pressure ulcer. What
action should the nurse take first?
A. Administer the rectal suppository.
B. Replace the soiled dressing. <
C. Assess the clients bowel sounds.
D. Check the client for an impaction.

31. The nurse is assessing a 48-year-old client with Guillain-Barre syndrome. What
symptom is this client most likely to exhibit?
A. Pill rolling movement of the fingers.
B. Difficulty keeping eyelids open.
C. Pain on one side of the face.
D. Decreased mobility of the legs. <
32. The emergency department notifies the charge nurse at 3:00 a.m. of the transfer of
a client who is being admitted because of multiple lacerations that are a result of
self-destructive behavior. Agency policy states that this client should be admitted
to a safe room with window locks, but the only safe room on the unit is currently
occupied by a postoperative client. What action should the nurse take?
A. Admit the client to a regular room and provide intensive monitoring.
B. Have the client remain in the emergency department until morning.
C. Move the postoperative client to another room. <
D. Decline the client because a safe room is unavailable.

33. The nurse is caring for a two-day postoperative client. What assessment finding
indicates that wound healing is likely?
A. Tolerated a full liquid diet on the second postoperative day.
B. Ambulated in the hallway 24 hours after surgery.
C. Current serum potassium level is 4.9 mEq/L.
D. Total serum protein is 5.4 g/dl. <

34. A clients arterial blood gases are: pH 7.5, PaO2 94, PaCO2 30, HCO2 24. What
action should the nurse take based on these findings?
A. Auscultate the clients breath sounds for increased secretions.
B. Review the clients electrolytes and intake/output for fluid balance.
C. Assess the client for nausea, vomiting, or diarrhea.
D. Assess the client for causes of hyperventilation. <

35. A Code Pink is announced over the hospital intercom system, indicating that a
baby has been abducted from the nursery. What action should the charge nurse on
a medical surgical unit implement first?
A. Assign one UAP to report to the nursery to assist with the search.
B. Instruct the nursing staff to check every clients room, bathroom, and
treatment room.
C. Assign one staff member to stay at each of the emergency exits and stairwell
doors. <
D. Stay alert for further announcements because a code pink primarily affects
maternity units.

36. A client who is experiencing paranoid ideation is admitted to the psychiatric unit.
During the first 48 hours of treatment, which nursing intervention is best for the
nurse to implement?
A. Place the client in group activities with other paranoid clients.
B. Encourage the client to participate in unit social activities.
C. Refer the client to occupational therapy.
D. Allow the client to initiate relationships and activities. <
37. Which surveillance clues are specific potential indicators of a bioterrorism attack?
(Select all that apply.)
A. Geographic clustering of client illnesses. <
B. Increased rate of hospital emergency room visits.
 C. Emergency room understaffing for six consecutive shifts.
D. Increased prevalence of cases previously not seen in a geographic area. <
E. Increased biosafety practice precautions used by emergency room staff.
F. Unusual age distribution for a common disease. <

38. A client in acute renal failure has a serum potassium level of 6.3 mEq/L. What
medication can the nurse expect the healthcare provider to prescribe?
A. Nitrofurantoin (Macrodantin) orally.
B. Erythropoietin (Epogen) intravenously.
C. Kayexalate retention enema. <
D. Azathioprine (Imuran) orally.

39. The nurse finds a client at 33-weeks gestation in cardiac arrest. What adaptation
to cardiopulmonary resuscitation (CPR) should the nurse implement?
A. Position a hip wedge for lateral uterine displacement. <
B. Adjust the ventilation-to-compression ratio to 3:20.
C. Apply less compression force to reduce aspiration.
D. Apply oxygen mask after opening the airway.

40. A client has produced the first of a series of sputum samples for cytology. What
action should the nurse implement?
A. Ensure the client remains NPO until all the samples are collected.
B. Discard the initial sample and document the time it was obtained.
C. Transport the sputum container to the laboratory in a biohazard bag. <
D. Document the time the client last ate or drank on the laboratory slip.

41. In scheduling home visits, which client is best for the home health charge nurse to
assign to the licensed practical nurse (LPN)?
A. A client who needs the first postoperative dressing change following a skin
graft to the lower leg.
B. A postoperative client who no longer needs wound care, but has called to
report a fever.
C. A client with diabetes who has called to report a newly discovered foot
ulceration.
D. A bedfast client who needs daily irrigation of a stage 4 pressure ulcer. <

42. A client is hospitalized for pregnancy-induced hypertension (PIH) and is receiving

magnesium sulfate 2 g/hour IV. Which medication should the nurse plan to have
immediately available for this client?
A. Sodium bicarbonate.
B. Atropine.
C. Epinephrine.
D. Calcium gluconate. <

43. Which statement by the mother of a male toddler with croup indicates to the nurse
that the teaching was effective?
 A. I need to take him to the nearest ER immediately if he starts having trouble
swallowing. <
B. The cough makes him sound sicker than he is. I dont need to worry.
C. I can give him baby aspirin for the fever and cough.
D. Using a steam vaporizer at night in his room will help ease the cough.

44. The healthcare provider prescribes meperidine (Demerol) 25 mg IV every 3 hours

for an older, postoperative client. The nurse prepares the prescribed dose from a
cartridge labeled meperidine 75 mg/ml and dilutes the medication with 5 ml of
normal saline for IV administration. How many ml is the total volume of diluted
medication? (Enter numeric value only. If rounding is required, round to the
nearest tenth.) 5.3

45. Which assessment finding indicates to the nurse that resolution of a clients
subcutaneous emphysema has occurred?
A. No crepitus palpated at site. <
B. Client denies pain or tenderness at site.
C. No lymph node enlargement.
D. No redness or inflammation noted.

46. One hour after receiving the initial dose of doxazosin (Cardura), a male client
with benign prostatic hypertrophy complains of a rapid heartbeat and dizziness.
He is sitting at the side of the bed finishing his bedtime snack. His radial pulse is
144 beats/minute. What action should the nurse take first?
A. Assist the client to a recumbent position.
B. Notify the healthcare provider.
C. Obtain his blood pressure and apical pulse rate. <
D. Obtain an electrocardiogram (ECG).

47. When preparing the client for a thoracentesis, it is essential for the nurse to take
which action?
A. Have the client lie in the prone position. <
B. Determine if chest x-rays have been completed.
C. Encourage the client to cough during the procedure.
D. Ask the client to void prior to the procedure.

48. The nurse is preparing a disaster plan for a community. When planning for a
potential bioterrorism attack, which disease should be considered?
A. Shigellosis.
B. West Nile virus.
C. Pertussis.
D. Tularemia. <

49. The nurse has completed discharge teaching with a client who had perineal
surgery one week ago. Which statement by the client indicates that the teaching
was effective?
 A. I will try to avoid eating fruits and vegetables.
B. I will limit my fluid intake to about a quart a day.
C. I will cleanse the perineum after every bowel movement. <
D. I will only use enemas if I do not have a daily bowel movement.

50. A male client tells the nurse that he has experienced acid reflux for several years.
The nurse recognizes that this client has an increased risk for what problem?
A. Cancer. <
B. Cardiac disease.
C. Abdominal aneurysm.
D. Lymphadenopathy.

51. Which equipment should the nurse use to administer iron to an infant with iron
deficiency anemia?
A. Rectal suppository.
B. Medicine dropper. <
C. Medicine cup.
D. IV pump.

52. A 25 year-old male client with testicular carcinoma is scheduled for a unilateral
orchiectomy tomorrow. During the preoperative preparation, he tells the nurse that
he is concerned that his scrotum will not look normal after the surgery, even
though he knows that a testicular prosthesis will be inserted during surgery. What
immediate response is best for the nurse to provide?
A. Explain that the prosthesis feels and looks natural in the scrotum. <
B. Refer the client to a support group for young adults with cancer.
C. Reassure the client that no one will know just by looking at him.
D. Arrange for a recipient of testicular prosthesis to visit the client.

53. An adult male client presents to the psychiatric clinic accompanied by his mother
who is concerned that her child is going to jail because he broke into a jewelry
store. The nurse conducts an intake assessment and determines that the son is
using marijuana daily. What information should the nurse provide this mother?
A. Describe the consequences of enabling behaviors. <
B. Suggest to the mother that she allow her son to go to jail.
C. Refer the son to a drug treatment program immediately.
D. Tell the mother to discourage her sons marijuana use.

54. The nurse plans to frequently monitor the skin color, mucous membranes, and nail
beds of a client with acute renal failure (ARF). What is the purpose in carrying
out this nursing intervention?
A. Identify early signs of infections.
B. Identify early signs of dietary deficiencies.
C. Detect signs of anemia. <
D. Assess for signs of jaundice.
55. A 7-year-old with Guillain-Barre syndrome is admitted with ascending paralysis
to the C-6 level. In developing a plan to prevent disease until the paralysis
subsides, which intervention is most important for the nurse to include in the
childs plan of care?
A. Emotional support and diversional, educational activities.
B. Adequate fluid intake and hygienic care for an indwelling catheter.
C. Bowel incontinent care and skin care to bony prominences.
D. Range of motion and passive exercises of all large muscle groups. <

56. A female client who is being prepared for a hysterosalpingogram (HSG) informs
the nurse that she is allergic to shellfish. What action should the nurse implement?
A. Administer an antihistamine before the HSG.
B. Document the clients allergy.
C. Notify the healthcare provider. <
D. Ensure that a latex-free supply cart is available.

57. Returning to the office after seeing a homebound client, the home health care
nurse has many telephone messages from the assigned caseload. Which telephone
message should the nurse return first?
A. A young adult who was discharged from the hospital yesterday and is not
feeling well. <
B. An older adult with Type 2 diabetes who complains of intense itching of both
feet.
C. An adult client with a peripheral saline lock with redness at the insertion site.
D. A middle-aged client with a sigmoid colostomy who has irritation around the
stoma.

58. A client with hypertension is scheduled to receive a dose of the alpha-beta

adrenergic blocking agent carvedilol (Coreg). Which of the clients vital signs
warrants notification of the healthcare provider prior to administering the
scheduled dose?
A. Temperature of 101.4 F.
B. Blood pressure of 170/92.
C. Pulse rate of 42 beats/minute. <
D. Respiratory rate of 12 breaths/minute.

59. A 45-year-old female client who had a hysterectomy one week ago asks the nurse
when she will start to experience hot flashes. Before responding to the clients
question, what information should the nurse obtain?
A. The reason why the hysterectomy was performed.
B. The type of birth control used preoperatively.
C. The type of hysterectomy that was performed.
D. Whether the clients ovaries were also removed. <

60. After sitting outside, an elderly male who is attending an adult daycare center
develops uticaria and a macular rash with raised wheals over most of his trunk.
 He is slightly dyspneic, and is furiously scratching the rash with both hands. What
action should the nurse take first?
A. Call 911 to transport the client to an emergency center. <
B. Assess the vital signs q15 minutes for one hour.
C. Ask the client if there were any fire ants on the patio.
D. Cover the hives with a topical antihistamine cream.

61. A client with an indwelling urinary catheter has developed hematuria in the last
four hours. What action should the nurse implement?
A. Assist the client to a right side-lying position in the bed.
B. Determine if the client is receiving any anticoagulant medications. <
C. Withhold further oral fluids until the healthcare provider is notified.
D. Remove the clients indwelling urinary catheter immediately.

62. The charge nurse observes a male healthcare provider viewing his sisters record
on the computer monitor. What action should the nurse take?
A. Remind the healthcare provider that only the treatment team should view the
clients records. <
B. Tell the healthcare provider to maintain confidentiality of the contents in his
sisters record.
C. Allow the healthcare provider to continue viewing the clients medical record.
D. Ask the client if she gave her brother permission to view her record.

63. While receiving the first of two prescribed units of packed red blood cells, a client
develops a low-grade fever, flushing, and uticaria, so the nurse stops the
transfusion. What action should the nurse implement next?
A. Notify the healthcare provider of the clients reaction to the transfusion.
B. Obtain the second unit of packed red blood cells from the blood bank.
C. Start a second IV line to administer emergency intravenous medications.
D. Maintain the patency of the IV site by infusing a normal saline solution. <

64. The nurse is working with an unlicensed assistive personnel (UAP) to prepare a
client who had hip replacement surgery for transfer to the rehabilitation unit. A
practical nurse (PN) enters the room and reports that a client with pneumonia has
become confused and combative. What action should the nurse implement?
A. Ask the UAP to continue packing the belongings of the surgical client while
the two nurses return to the room of the combative client. <
B. Continue to prepare the surgical client for the transfer and instruct the PN to
apply restraints to the combative client.
C. Assign the UAP to stay with the combative client until the two nurses have
transferred the surgical client to the rehabilitation unit.
D. Assess the combative client after asking the PN to help the UAP prepare the
surgical client for transfer to the rehabilitation unit.
65. At a 2-year-old well-child visit, a toddlers parent tells the nurse that this child,
who is the youngest of five, rarely talks spontaneously. Which intervention should
the nurse implement?
A. Demonstrate games requiring expressive speech.
B. Suggest that the parent read aloud to the child at bedtime.
C. Schedule an appointment with pediatric audiologist. <
D. Encourage the parent to enroll in preschool classes.

66. An 82-year-old female client is hospitalized with a fractured femur. During a

routine nursing assessment, she repeatedly asks the nurse to speak up so that
she can hear the questions. Which action is best for the nurse to take?
A. Over-enunciate word syllables.
B. Decrease speaking speed. <
C. Raise voice volume to a shout.
D. Exaggerate nonverbal expressions.

67. A 79-year-old female client with chronic obstructive pulmonary disease (COPD)
asks why she has a round chest. The nurse correctly responds that the typical
barrel-chest appearance of an emphysema client is caused by which condition?
A. Constant coughing.
B. Abdominal breathing.
C. Upper body exercises to increase lung capacity.
D. Hyperinflation of the lungs. <

68. Vaginal exam of a client who is admitted in early labor reveals cervical dilation of
2 cm with 50% effacement and a -3 fetal station. The client tells the nurse that a
friends bag of waters was ruptured by the doctor to make labor progress faster,
and she is concerned because her doctor did not rupture the membranes. What
response is best for the nurse to provide?
A. The babys cord can prolapse if the fetal head is high in the pelvis. <
B. Cervical dilatation to 4 cm is needed to rupture the membranes.
C. The bag of waters is not ruptured until the birth is imminent.
D. Rupturing the bag of waters does not have any effect on labor.

69. The nurse plans to administer a 0.5 ml intramuscular injection to an 18-month-old

toddler in the vastus lateralis. What is the rationale for choosing this site?
A. This injection site is the easiest to expose fully at this age.
B. The mother of the child can hold the child most securely when this site is
used.
C. This injection site has the fewest major blood vessels at this age.
D. This is the most developed muscle until the child has been walking longer. <

70. Social isolation is identified as a nursing diagnosis for a 16-year-old who is

experiencing facial edema. What behavior indicates a positive outcome for this
diagnosis? The client
A. Is quietly watching television.
 B. Requests that visitors be restricted.
C. Sleeps soundly through the night.
D. Is laughing and talking on the phone. <

71. In planning strategies to promote client rest and sleep during the night shift, the
nurse should encourage the staff to adhere to which guideline?
A. Keep the nurses station free of excessive debris and clutter.
B. Exchange shift report in a private room with the door closed. <
C. Wear dark colored scrub suits, uniforms, and lab jackets.
D. Make sure bright lighting is maintained in the hallways.

72. The nurse is planning care for a client who is newly diagnosed with type 1
diabetes mellitus (DM). What nursing intervention should the nurse include in this
clients plan of care?
A. Give an oral hypoglycemic agent per sliding scale.
B. Check each voided urine for sugar and ketones.
C. Monitor blood glucose levels every 6 hours.
D. Teach diabetic information at every opportunity. <

73. The nurse is evaluating preoperative teaching. What statement by the client
indicates an understanding of the need to remain NPO prior to surgery?
A. My intestines need to be empty during surgery.
B. Less fluid will collect in my lungs.
C. I will be less likely to vomit after surgery.
D. Theres less chance I will vomit during surgery. <

74. A resident of a long-term care facility falls during the night. After determining the
resident has an obvious wrist injury and blunt head trauma, the charge nurse is
unable to reach the healthcare provider despite multiple calls to the pager and
answering service. Which action should the charge nurse implement?
A. Request permission from the family to transport the client to the hospital.
B. Refer the situation the Director of Nursing for further action.
C. Document the incident and transport the client to the hospital. <
D. Apply a wrist splint and continue to try contacting the healthcare provider.

75. A new plaster cast is applied to a clients arm for a fracture of the ulna. Sixty
minutes after receiving an analgesic, the client reports pain in the arm and scores
the intensity at 10 on a scale of 1 to 10. Which action is most important for the
nurse to perform?
A. Teach the client to wiggle the fingers.
B. Contact provider for a different analgesic.
C. Elevate the extremity on two pillows.
D. Assess for distal paresthesia. <

76. Which assessment finding contraindicates removal of staples from a surgical

incision?
 A. Incision edges are well approximated.
B. Client complains of incisional itching and discomfort.
C. No evisceration present entire length of incision.
D. Partial dehiscence noted at incisions distal end. <

77. A client is admitted to the Emergency Department with acute abdominal pain and
a provisional diagnosis of pancreatitis. The nurse assesses the client and results
from laboratory studies are obtained. Which information is most valuable in
reporting the clients status to the healthcare provider?
A. Severity of nausea and vomiting and serum amylase results. <
B. Presence of bowel sounds and degree of abdominal pain.
C. Serum H. pylori antibody results and urine output amounts.
D. Complaints of chronic constipation and serum gastrin levels.

78. A client with dementia describes imagined experiences that have no basis in fact,
and a nursing diagnosis of Altered thought processes related to confabulation is
formulated. What main function does confabulation serve for client with
dementia?
A. Increase self-esteem.
B. Decrease anxiety. <
C. Keep the conversation going.
D. Impress others.

79. A man who was trapped for 2 days on the roof of his home awaiting rescue during
a weather-related disaster spent several weeks in a shelter. During this time, he
says he wondered if he was going to die like many of his friends and relatives
had. Now, several months later, he reports feeling numb and cannot relate well
with others. He sometimes relives the isolation and anxiety associated with the
ordeal. Nursing care should be directed toward which outcome?
A. Uses time productively when conducting activities of daily living and during
social or recreational activities.
B. Exhibits a more positive self-evaluation when describing himself.
C. Responds to his name when addressed by a member of the treatment team.
D. Implements anxiety-control strategies such as progressive relaxation and
thought substitution. <

80. While assessing a client who had a laparotomy the previous day, the nurse notices
that 300 ml of dark red fluid has drained from the nasogastric tube in the last hour.
What action should the nurse take first?
A. Monitor urinary output hourly.
B. Determine the clients vital signs. <
C. Assess the clients level of pain.
D. Notify the surgeon immediately.
81. After administering an injection, the nurse observes bleeding at the site. In what
sequence should the nurse perform these actions? (Arrange with the first step on
top and the last step on the bottom.)
2 - Apply an adhesive bandage over the injection site.
3 - Place syringe in a puncture-resistant container.
1 - Retract the needle into the syringe.
4 - Remove disposable exam gloves.

82. The nurse overhears two hospital employees discussing confidential client
information in the cafeteria. The nurse decides to intervene, because this situation
is a breach of which ethical principle.
A. Consistency.
B. Autonomy.
C. Veracity.
D. Fidelity. <

83. The nurse is preparing to administer a liter of IV solution to a toddler with

gastroenteritis who is dehydrated. Which action should the nurse implement to
prevent fluid overload?
A. Ask another nurse to distract the child while spiking the IV bag.
B. Use tubing with secondary ports and a macro-drip chamber.
C. Attach a volume-control device below the primary infusion. <
D. Immobilize the hand with the IV access device to an arm board.

84. While assessing a 6-year-old, the nurse notices several elevated 1 to 3 mm white
spots on the childs buccal mucosa. What other signs should the nurse expect this
child to exhibit?
A. Irregular red macular rash in the perianal area.
B. Red blotchy macular rash on the face and neck. <
C. Pruritic vesicular skin eruptions on trunk.
D. Honey-colored crusted exudate from ruptured skin vesicles.

85. In evaluating teaching of a client about wearing a Holter monitor, which statement
made by the client would indicate to the nurse that the client understands the
procedure?
A. I must record any symptoms occurring with my activity. <
B. I am not looking forward to staying in bed for 24 hours.
C. I really am dreading the frequent blood drawing.
D. I know that I shouldnt get close to my microwave oven.

86. A female client diagnosed with major depression was admitted to the psychiatric
unit yesterday. Today she refuses to take a bath, dress, or eat, and wants to sleep
during the day. Which intervention has the highest priority for this client?
A. Request a meeting with the family to discuss her behavior.
B. Provide and maintain a safe, structured daily routine. <
C. Administer the prescribed intramuscular antidepressant medication.
 D. Assess the clients ability to communicate with the staff.

87. A client with chronic controlled atrial fibrillation develops symptoms of a

pulmonary embolus. What intervention has the highest priority?
A. Monitor oxygen saturation via pulse oximeter. <
B. Evaluate the clients most recent INR result.
C. Determine if the client converted to a sinus rhythm.
D. Administer PRN IV morphine to control anxiety.

88. A school-aged child with otitis media receives a prescription for azithromycin
(Zithromax) 300 mg once, then 150 mg daily for 4 days. The medication is
available in a solution containing 200 mg/5 ml. How many ml should the nurse
administer on the first day of the treatment regimen? (Enter numeric value only. If
rounding is necessary, round to the nearest tenth.) 7.5

89. A nurse is concerned about the type of legal consequences that can result from
breaching client confidentiality. What source states the legal requirements nurses
must follow to protect client confidentiality in a nurse-patient relationship?
A. Amendments to the Federal Constitution.
B. Patients Bill of Rights Acts.
C. State Nurse Practice Acts. <
D. ANA Code of Ethics for Nurses.

90. The nurse is performing an intake interview at a prenatal clinic. Which planned
activity described by the client, who is at 6-weeks gestation, should be
investigated by the nurse first?
A. A scheduled business trip in 3 weeks that includes travel by airplane and train.
B. Plans to continue participating in a low-impact aerobics class.
C. The 9-year-old sibling will come with the client to the next prenatal visit.
D. Supervision of the renovation of an old house the family just purchased. <

91. A young adult male client is admitted to the psychiatric unit because of a drug
overdose. Which nursing intervention is most important when planning prioritized
care for this client during the initial drug withdrawal period?
A. Limit visitors who might bring the client drugs.
B. Monitor the clients physical response to withdrawal. <
C. Plan activities to increase the clients self-esteem.
D. Help the client gain insight into his behavior.

92. What area of the body should be palpated to assess for the presence of Heberdens
nodes in the client with osteoarthritis?
A. Lower spine.
B. Knee and hip joints.
C. Face and neck.
D. Distal fingers. <
93. An infant is receiving gavage feedings via an orogastric tube. At the beginning of
the feeding, the infants heart rate drops to 80 beats/minute. What action should
the nurse take?
A. Slow the feeding and monitor the infants response. <
B. Immediately clamp and remove the orogastric tube.
C. Shift the infants position to the right lateral side.
D. Continue feeding since this is a typical response.

94. A 40-year-old client with Type 1 diabetes developed chronic kidney disease
(CKD) 6 months ago. Because of secondary complications often associated with
this illness, the nurse plans to carefully assess for signs of what condition?
A. Anemia. <
B. Kidney stones.
C. Rheumatoid arthritis.
D. Bacterial endocarditis.

95. The nurse is developing the plan of care for a client who is returning from surgery
after a total colectomy and ileostomy. Which nursing diagnosis has the highest
priority for this client during the immediate postoperative period?
A. Risk for impaired skin integrity related to fecal drainage.
B. Knowledge deficit related to surgical bowel diversion.
C. Risk for electrolyte imbalance related to ileostomy. <
D. Risk for sexual dysfunction related to pelvic nerve injury.
96. Which approach is best for the nurse to use when communicating with a client
with amyotrophic lateral sclerosis (ALS)?
A. Speak clearly, slowly, and loudly.
B. Reorient the client frequently.
C. Use visual cues to increase comprehension.
D. Demonstrate a positive, caring demeanor. <

97. A client diagnosed with schizophrenia looks frightened and tells the nurse, I keep
hearing the voices telling me to hurt somebody. Dont you hear them? Which
response is best for the nurse to provide?
A. If you keep taking your medication the voices will go away.
B. The voices are not real. They are part of your illness.
C. I dont hear the voices, but you seem very frightened. <
D. Just ignore the voices and pretend they are not there.

98. A client newly diagnosed with Type 1 diabetes received 28 units of Humulin N at
0700. The nurse is making rounds at 1330. Which client statement requires the
most immediate follow-up intervention by the nurse?
A. I let my wife eat my lunch since I wasnt hungry. <
B. I get so nervous when I have to give my shot.
C. I didnt sleep well last night. I am going to take a nap.
D. I get dizzy when I get up out of the bed too fast.
99. During breath sound auscultation of a client who is being mechanically ventilated,
the nurse hears coarse, snoring sounds over the upper anterior chest with clear
breath sounds over the other lung fields. What intervention should the nurse
implement at this time?
A. Suction the clients endotracheal tube. <
B. Notify respiratory therapy immediately.
C. Continue to assess the client frequently.
D. Begin manual resuscitation with ambu bag.

100. At a community health fair, a 50-year-old woman tells the nurse that she
has an annual physical exam that includes a clinical breast exam and an annual
mammogram. How should the nurse respond?
A. Ask the woman if she also performs monthly breast self-exams. <
B. Advise the woman that mammograms are only needed every two years at her
age.
C. Encourage the woman to explore her fears about breast cancer.
D. Comment the woman for adhering to the recommended cancer detection
guidelines.

101. An adult woman and her live-in boyfriend are seen in the Emergency
Department following a motor vehicle collision. Based on which finding should
the nurse assess further for the possibility of domestic violence?
A. The woman is demanding and argumentative with staff.
B. The couple is vague about how the collision occurred.
C. Several old bruises appear on the womans chest and neck. <
D. Her live-in boyfriend seems unconcerned about her condition.

102. The nurse knows the client with a mechanical valve replacement
understands the discharge teaching when the client makes which statement?
A. I should notify my healthcare provider if I hear a clicking sound near my
heart.
B. I will need to take antibiotics before any type of invasive dental work. <
C. I will not have to take any more heart medication since I have a new valve.
D. I will need to have this valve replaced in about 10 years.

103. While reporting a clients blood glucose results to the nurse, the LPN
states that the glucometer was not calibrated prior to use because the report given
by the night shift ran late. What action is most important for the nurse to perform.
A. Advise the LPN of the implications involved by not calibrating the
glucometer. <
B. Complete a variance report describing the inaccurate blood glucose
measurements.
C. Discuss the need for a more efficient shift report with the night charge nurse.
D. Ask the supervisor to schedule an in-service training on the correct use of
glucometers.
104. A female client is instructed to do Kegel exercises. What statement
identifies to the nurse that the client understands how to perform these exercises?
A. I need to tighten my stomach muscles while sitting and standing, hold for 10
seconds, and repeat 5 times.
B. When I urinate, I should tighten those muscles and stop the flow of urine for
10 seconds and repeat this 5 to 10 times. <
C. I need to press the small of my back against a chair and hold for 5 seconds,
repeating this 10 times.
D. While lying on my back, I need to do modified sit-ups at least twice a day.

105. The charge nurse should intervene when what behavior is observed?
A. A hospital transporter is reading a clients history and physical while waiting
for an elevator. <
B. A UAP tells a client, Its hard to quit drinking but Alcoholic Anonymous
helped me.
C. Two visitors are discussing a hospitalized clients history of drug abuse in the
visitors lounge.
D. Two staff members are overheard talking about a cure for AIDS outside a
clients room.

106. A client who had a left above knee amputation (AKA) two days ago has a
soft stump dressing in place. To prevent the development of a contracture on the
left leg, which intervention should the nurse implement?
A. Turn the client to the unaffected side only.
B. Elevate the clients left leg on two pillows at all times.
C. Instruct the client to push the stump against a soft pillow.
D. Position the client prone 3 to 4 times a day. <

107. An ACE inhibitor is prescribed for a male client with diabetes whose
blood pressure is 120/60 mm Hg. The client asks the nurse why he is receiving the
medication when his blood pressure is normal. The nurses response should be
based on what information?
A. It lowers insulin resistance at the cellular level in Type 1 diabetics.
B. It helps to prevent gastric reflux and gastroparesis associated with diabetes.
C. It helps prevent platelet aggregation and plaque formation in diabetics.
D. It slows the progression of kidney damage often associated with diabetics. <

108. When irrigating an occluded nasogastric tube, what action should the nurse
include?
A. Check the stomach for the amount of residual volume.
B. Clamp the tube after instilling the normal saline.
C. Measure the amount of fluid instilled and returned. <
D. Lubricate the tip of the syringe before insertion.

109. The nursing diagnosis, High risk for infection is most relevant for a
client with which hematologic problem?
 A. Agranulocytosis. <
B. Thrombocytopenia.
C. Erythrocytopenia.
D. Polycythemia.

110. Thirty-six hours after delivery, the nurse assesses a clients fundus just
above the umbilicus and displaced to the right of midline. What action should the
nurse take first?
A. Assess the amount of lochia.
B. Catheterize the client and record the amount.
C. Palpate the bladder for distention. <
D. Ask the client when her last bowel movement occurred.

111. In assessing a client diagnosed with left-sided heart failure, the nurse
observes new findings of jugular vein distention and pedal edema. What action
should the nurse implement?
A. Position the client in a left lateral Trendelenburg position.
B. Advise the client that thrombolytic therapy will be started immediately.
C. Notify the healthcare provider of the onset of right-sided failure. <
D. Prepare to administer an intravenous vasoconstricting agent.

112. Identify the location of the tragus on the outer auricle. (Click the chosen
location. To change, click on a new location.)

113. A client has an AV graft for hemodialysis in the left forearm and an
infiltrated IV in the right arm. After discontinuing the IV, where should the next
IV be started?
A. Right arm proximal to the former IV. <
B. Use AV graft for IV access.
C. Left arm proximal to the graft.
D. Left arm distal to the graft.

114. A 10-year-old boy reports that the words on his teachers power point
presentations are blurry even though he sits in the front row of the classroom.
Based on this description, the school nurse should suspect which problem?
A. Exotropia.
B. Farsightedness.
C. Myopia. <
D. Hyperopia.

115. After administering phenobarbital to an infant with increased intracranial

pressure, which response should the nurse expect?
A. The infant is sleepy and less irritable. <
B. Infant take clear liquids without vomiting.
C. Increased heart and respiratory rate.
D. The infants urinary output increases.
116. The healthcare provider prescribes etanercept (Enbrel) 50 mg subcutaneously
weekly for a client with rheumatoid arthritis. The nurse should evaluate the
effectiveness of this medication within what time frame?
A. Once every 6 months.
B. Daily for one week.
C. Every 4 months for one year.
D. 2 to 4 weeks. <

117. A male client with a history of generalized tonic-clonic seizures tells the nurse
that he feels like he is about to have a seizure. What should the nurse do first?
A. Perform a neurological assessment.
B. Give a STAT dose of an anticonvulsant medication.
C. Check clients oxygen saturation level.
D. Stay with the client and call for assistance. <
118. The nurse gives a client the daily dose of a prescription for captopril (Capoten)
12.5 mg PO every AM. Shortly after administering the medication, the healthcare
provider instructs the nurse to give another dose to reach the newly prescribed
dose of 50 mg PO daily. The medication is available in 12.5 tablets. How many
additional tablets should the nurse give? (Enter the numeric value only.) 3

119. A client is receiving an intermittent infusion of erythromycin lactobionate for

injection, USP (Erythrocin Lactobionate) 1 gram in 250 ml of normal saline over
two hours. The nurse should program the infusion pump to deliver how many
ml/hour? (Enter numeric value only.) 125

120.A one-day-old neonate is awaiting surgical correction of a myelomeningocele.

During the preoperative period, what is the priority nursing intervention?
A. Observe for CNS infection related to sac trauma. <
B. Position supine to protect the sac from urine and feces.
C. Maintain the neonate on a pressure-reducing surface.
D. Minimize the neonates exposure to latex products.

121.A female client who has just completed a full chemotherapy cycle for cancer has
lost 15 pounds because of anorexia, nausea, and vomiting. Her BMI is 19. The
nurse reinforces nutritional concepts during discharge planning. Which dinner
menu selection best indicates that the client understands her nutritional needs?
A. Vegetarian spaghetti, garlic bread, Caesar salad, apple pie, and iced tea.
B. Lean hamburger patty, tomato and lettuce, sugar-free gelatin, cantaloupe, and
diet soda.
C. Fried chicken breast, sweet potato, spinach, roll and butter, and protein milk
shake. <
D. Grilled chicken breast with no skin, broccoli, fresh fruit, and skin milk.

122.The nurse is caring for a dyspneic client whose oxygen saturation rate is
currently 90%. What position is best for this client?
 A. Sims with a pillow under the upper leg.
B. Any position that is comfortable.
C. Supine with the legs slightly elevated.
D. Fowlers with both legs supported. <

123.When obtaining a health history, a male client tells the nurse that he has become
impotent. What part of his health information is likely to be most significant to
the sexual dysfunction he is experiencing? The client
A. drinks two to three beers on weekend.
B. Was diagnosed with diabetes mellitus 10 years ago. <
C. Had a vasectomy five years ago.
D. Smokes one pack of cigarettes a day.
124.The mother of a hospitalized 2-year-old boy asks the nurse if her child is ready to
be toilet trained. Which response is best for the nurse to provide?
A. Yes, most children are ready when they are 15-months old.
B. We have potty chairs here. Would you like to start working with him on it
now?
C. He will train quicker and more easily if you wait until he is in a familiar
environment.
D. Does he let you know just before or after he soils his diaper? <

125.A nurse agrees to work a double shift because of a staffing shortage, but requests
that another nurse be assigned to care for a demanding client. What response is
best for the charge nurse to make?
A. Im sorry, but you know I cannot allow you to choose your assignments.
B. Ill assign the client to another nurse, but your help may be needed. <
C. I would appreciate you reconsidering since you are always so good with
difficult clients.
D. Youll probably need to keep the same assignment so that continuity of care
can be provided.

126.The nurse is evaluating teaching about short-acting insulin coverage to a client

newly diagnosed with Type 1 diabetes. Which statement by the client indicates
an understanding of short acting insulin coverage?
A. After taking my regular insulin, I need to eat a meal soon to prevent a
hypoglycemic episode. <
B. I can eat whatever I want, just as long s I check my blood sugar and cover it
appropriately.
C. When meeting a friend for lunch, it is OK to take my coverage at home
before driving to the restaurant.
D. I need to check my sugar also at bedtime, and then give my coverage before
going to sleep.

127.A client is admitted to an inpatient psychiatric unit, and the antipsychotic

medication clozapine (Clozaril) is prescribed. Which intervention should the
nurse include in the clients plan of care?
 A. Report findings from the clients weekly white blood cell (WBC) counts to
the healthcare provider. <
B. Inform UAPs that the client will likely complain of a sore throat and fever.
C. Offer this medication the client with food to decrease the possibility of
gastric upset.
D. Place the client in reverse isolation for the first two weeks of treatment with
this medication.

128.The nurse is assessing a client who is eight hours post parathyroidectomy.

Assessment findings include a negative Trousseaus sign. What action should the
nurse implement?
A. Document the findings. <
B. Notify the healthcare provider.
C. Obtain a serum calcium level.
D. Administer IV calcium chloride.

129.The nurse is preparing a Native-American client for surgery in one hour. The
client states, I want to have my medicine man called before surgery. How
should the nurse respond?
A. Tell me how you believe that your medicine man will be able to help you.
B. I will be happy to assist you in contacting your medicine man right away. <
C. The hospital chaplain is available and can meet with you before surgery.
D. Your medicine man is too far away to visit before your scheduled surgery.

130.The nurse is calculating the one-minute Apgar score for a newborn male infant,
and determines that his heart rate is 150 beats/minute, he has a vigorous cry, his
muscle tone is good with total flexion, he has quick reflex irritability, and his
color is dusky and cyanotic. What Apgar score should the nurse assign to the
infant? (Enter the numeric value only.) 8

131.The nurse is administering an IV medication through a central venous catheter

with a heparin loc. Which sequence of medication administration should the
nurse follow?
A. Saline, heparin, medication, heparin.
B. Saline, medication, saline, heparin. <
C. Medication, heparin, saline, heparin.
D. Heparin, medication, heparin, saline.

132.After receiving the change of shift report on the psychiatric unit of a general
hospital, which client should the nurse assess first?
A. A male client with paranoid schizophrenia who thinks his food is poisoned.
B. A 20-year-old client who is trying to telephone the President of the United
States.
C. A female client who is pacing the hallway and trying to sell her clothes.
D. A client with depression who states she is leaving because she feels better. <
133.The nurse is caring for a client who is being treated for fever. What nursing
intervention is most important to prevent chills?
A. Assess clients temperature q4h.
B. Offer a cup of hot tea q8h.
C. Give prescribed antipyretics around the clock. <
D. Provide a sponge bath q8h.

134.To assess a client with meningitis for meningeal irritation, how should the nurse
position the clients head?
A. The neck and head are twisted toward the shoulder.
B. The head and neck are flexed toward the chest. <
C. The ear is flexed downward toward the shoulder.
D. The head and neck are extended toward the back.

135.A client diagnosed with severe acute diverticulitis is being admitted to the
medical unit. Which prescription should the nurse question?
A. Bisacodyl (Dulcolax) rectally PRN for constipation. <
B. Meperidine (Demerol) ICP PRN for pain.
C. Cefoxitin (Mefoxin) IVPB q8h.
D. 5% dextrose with 0.45 NS at 125 ml an hour.

136.The nurse notes that a depressed adolescent clients fluoxetine (Prozac) cannot be
given because the mother refuses to sign the consent for medication. What should
the nurse do?
A. Give the medication if the client is willing to take it.
B. Obtain two witnesses and ask the client to sign the consent.
C. Determine if there is an emergency contact person to notify.
D. Wait for the mother to sign the medication consent. <

137.A child is injured at a sporting event and a nurse attending the event evaluates the
child. What is the most accurate method to determine if a fracture has occurred?
A. Palpate the injured part.
B. Send the child for a radiological exam. <
C. Observe for decreased range of motion.
D. Assess the level of swelling and pain on movement.

138.The nurse working in a health clinic is assessing clients needs for a hepatitis A
vaccine. Which client has the greatest risk for contracting Hepatitis A?
A. Female client who regularly consumes raw oysters. <
B. An adolescent client who reports illicit IV drug use.
C. An elderly client with a large daily alcohol consumption.
D. Male client who has received multiple blood transfusions.

139.A client with depression remains in bed for most of the day, declines activities,
and refuses meals. Which nursing diagnosis has the greatest priority for this
client?
 A. Social isolation.
B. Feeding self-care deficit. <
C. Situational low self-esteem.
D. Deficit diversional activity.

140.Which intervention would the nurse expect to implement to decrease discomfort

and muscle spasms for an elderly client with a fractured left hip?
A. Prepare the client for application of Bucks traction. <
B. Remove the foam boot to perform range of motion exercises.
C. Prepare the client for application of Dunlops traction.
D. Inspect the pin site at least q8h for signs of infection.

141.In performing the admission assessment for a client experiencing complications

of long-term Parkinsons disease, which question by the nurse provides the best
information about disease progression?
A. Have you experienced any stiffness in your neck or shoulder?
B. Do you notice any jerky type movements of your arms?
C. Have you ever been frozen to a spot and unable to move? <
D. Do you have any problems with your hands shaking?

142.An 18-year-old female client with primary dysmenorrhea does not want to take
any medication to relieve the symptoms, and asks the nurse which herbal
supplement is likely to help alleviate the pain she is experiencing. What herbal
supplement is likely to be most helpful for this young woman?
A. Chamomile. <
B. Ginseng.
C. Yarrow.
D. Ginger.

143.Which assessment intervention should the psychiatric nurse implement when

performing a mental status exam?
A. Request the client hold out his/her tongue for one minute.
B. Have the client close his/her eyes and count slowly to 100.
C. Allow the client to discuss what brought him/her to the hospital.
D. Ask the client to interpret the proverb, A stitch in time saves nine. <

144.The nurse is conducting a routine assessment of a 24-hour-old, African-American

infant who was delivered vaginally. At birth the infants weight was 5 pounds 5
ounces, heart rate was 150 beats/minute, respiratory rate was 88 breaths/minute,
and the axillary temperature was 97.7 F. Which finding requires further
assessment?
A. Respiratory rate of 59 breaths/minute.
B. Edema present along the sagittal suture.
C. Weight loss of 10 ounces since birth. <
D. 2 cm bluish purple area on the scrotum.
145.Following the vaginal delivery of a 10-pound infant, the nurse assesses a new
mothers vaginal bleeding and finds that she has saturated two pads in 30 minutes
and has a boggy uterus. What action should the nurse take first?
A. Perform fundal massage until firm. <
B. Have the client empty her bladder.
C. Determine the clients blood pressure.
D. Increase oxytocin (Pitocin) IV rate.

146.A client with angina experiences chest pain after completing morning care. What
action should the nurse take first?
A. Administer a nitroglycerin tablet. <
B. Place a pulse oximetry probe to index finger.
C. Give an 81 mg Aspirin tablet.
D. Monitor for premature ventricular contractions.

147.A gravida 3, para 2 at 31-weeks gestation is admitted to the hospital with

suspected HELLP syndrome. She complains of nausea, vomiting, malaise, and
epigastric pain. Her blood pressure is 116/74. What assessment is most important
for the nurse to obtain?
A. Confirm gestational age with ultrasound.
B. Observe for signs of dehydration.
C. Evaluate the client for thrombocytopenia. <
D. Determine urine protein level.

148.A 60-year-old male client is admitted to the hospital complaining of right knee
pain for the past week. His right knee and calf are warm and edematous. He has a
history of diabetes and arthritis. During the admission assessment, which
information is most important for the nurse to obtain?
A. Medication history for the past two weeks.
B. Cardiac assessment of heart sounds.
C. A 24-hour recall of dietary intake.
D. Neurovascular status of lower extremities. <

149.The nurse observes a client standing with the use of crutches and notes that the
clients arms are fully extended and the tops of the crutches are securely pressed
in the clients axillae. Which intervention should the nurse initiate first?
A. Demonstrate the prescribed gait to the client.
B. Reduce the length of the clients crutches. <
C. Make sure that the rubber tips are in place on the crutches.
D. Instruct the client in the use of the tripod position.

150.The parents of a child with cystic fibrosis (CF) ask the nurse about their chances
of having another child with CF. Which response is best for the nurse to provide?
A. Male children have a greater chance of inheriting the autosomal recessive
gene.
 B. Since this child is affected future children will be carriers and will not be
affected.
C. 1 in 20 persons in the United States carry the recessive gene for cystic
fibrosis.
D. There is a 1 in 4 chance that any child of heterozygous parents will be
affected. <

151.A 12-year-old male is diagnosed with idiopathic hypopituitarism based on

plasma growth hormone studies. Subcutaneous injections of the human growth
hormone somatotropin (HGH) are prescribed three times a week. To promote the
most natural physiological release of growth hormone, when should the nurse
teach the child to administer the injections?
A. In the late afternoon.
B. Before going to school in the morning.
C. Before going to sleep at night. <
D. Before breakfast.

152.When planning care for a group of clients on a medical unit, which task can the
nurse delegate to the unlicensed assistive personnel (UAP)?
A. Complete a Braden Scale to predict pressure ulcer risk.
B. Prepare a schedule for positioning a bedfast client.
C. Use a mechanical lift to transfer a client to the chair. <
D. Determine if a client has learned how to use a walker.

153.To administer a saline enema to a client, the nurse inserts the enema tubing 3
inches into the clients rectum, and elevates the saline container 6 inches above
the clients body. After the nurse opens the clamp, the saline solution does not
infuse. What is the best action for the nurse to take?
A. Instruct the client to take several slow, deep breaths.
B. Raise the saline container 6 more inches above the body. <
C. Insert the tubing an additional 3 inches into the rectum.
D. Remove the tubing and check the client for fecal impaction.

154.A client who is receiving chemotherapy for lung cancer with brain metastasis is
scheduled for cranial radiation therapy (RT) today. The nurse should provide
which information about the procedure to the client?
A. Radiation precautions are implemented to limit exposure for everyone who
enters the clients room.
B. A high dose beam of radiation may cause a brief tingling sensation but will
not cause pain.
C. Skin markings and head positioning devices are used to ensure that only the
tumor site is radiated. <
D. A radioisotope is implanted into the tumor that limits chemotherapy side
effects for up to 30 days.
155.While inserting an indwelling catheter for a female client, the nurse observes that
the catheter is in the vagina. In what order should the nurse perform these
actions? (Arrange from first on top to last on the bottom.)
5 - Inflate the indwelling catheters balloon with sterile water.
1 - Leave the catheter in the vagina.
2 - Obtain a new catheterization kit.
4 - Insert the catheter and observe for a urinary return.
3 - Use forceps and cotton balls to cleanse the urethral meatus.
6 - Remove the wrongly placed catheter.

156.When assessing both lower extremities (BLE) of a client who has chronic venous
insufficiency, the nurse identities bilateral stasis dermatitis and an ulcer on the
medial surface of the left ankle. To promote effective self-care, which client
teaching should the nurse provide?
A. Soak feet to soften nails before trimming.
B. Keep legs dependent to promote blood flow.
C. Medicate inflamed skin areas with an antibiotic ointment.
D. Apply compression stockings before ambulation. <

157.A client at 40-weeks gestation is admitted in active labor, and laboratory findings
indicate that she is HIV positive. What actions should the nurse plan to perform?
(Select all that apply.)
A. Administer zidovudine (AZT) intravenously. <
B. Establish enteric isolation.
C. Place her in a negative pressure room.
D. Notify the pediatrician that the mother is HIV positive. <
E. Promote bonding by encouraging breastfeeding.
F. Use universal precautions. <

158.A toddler with hemophilia is being discharged from the hospital. Which teaching
should the nurse include in the discharge instructions to this childs mother?
A. Place padding on the corners of all furniture. <
B. Give the child only one baby aspirin for pain relief.
C. Ensure that dental hygiene is done frequently.
D. Do not allow the child run inside the house.

159.The nurse is preparing a male client for a bilateral adrenalectomy. Which

explanation should the nurse include in this clients preoperative teaching?
A. It will be necessary to take desmopressin acetate (DDAVP) for the rest of his
life.
B. Replacement therapy with corticosteroids will be needed for the rest of his
life. <
C. It will be necessary to take the prednisone for at least 6 weeks after surgery.
D. The surgery should relieve symptoms, so that no medication will be needed
after the adrenal glands are removed.
160.When a nurse with a history of drug impairment returns from a drug
rehabilitation program, what is the best initial action by the charge nurse?
A. Request that the nurse be transferred to another nursing unit.
B. Assign another staff person to observe the nurse administering medications.
C. Establish a contract with the nurse about role limitations. <
D. Assign the nurse to clerical responsibilities only.