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HESI Comprehensive Exit Exam With Correct Answers
1 - Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? A. Checking the client's blood pressure B. Checking the client's peripheral pulses C. Checking the most recent potassium level D. Checking the client's intake-and-output record for the last 24 hours - Correct answer A. Checking the client's blood pressure Checking the client's blood pressure Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One common side effect is postural hypotension. Therefore the nurse would check the client's blood pressure immediately before administering each dose. Checking the client's peripheral pulses, the results of the most recent potassium level, and the intake and output for the previous 24 hours are not specifically associated with this mediation. 2 - A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? A. "The test will take about 30 minutes." B. "I need to fast for 8 hours before the test." C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." D. "I need to take a laxative after the test is completed, because the liquid that I'll have to drink for the test can be constipating." - Correct answer C. "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30 minutes. No special preparation is necessary before a GI series, except that NPO status must be maintained for 8 hours before the test. After an upper GI series, the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to expel, leading to fecal impaction. 3 - A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should: A. Call the nursing supervisor B. Ask the answering service to contact the on-call physician C. Withhold the medication until the physician can be reached in the morning D. Administer the medication but consult the physician when he becomes available - Correct answer B. Ask the answering service to contact the on-call physician 4.An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is: A. Documenting the findings
B. Asking the ED physician to check the client C. Continuing to monitor the client's cardiac status D. Informing the client that PVCs are expected after an MI - Correct answer B. Asking the ED physician to check the client 5.NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should: A. Administer the antihypertensive with a small sip of water B. Withhold the antihypertensive and administer it at bedtime C. Administer the medication by way of the intravenous (IV) route D. Hold the antihypertensive and resume its administration on the day after the ECT - Correct answer A. Administer the antihypertensive with a small sip of water 6 A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? A. "Tell me more about what you're feeling." B. "That's a normal response after this type of surgery." C. "It will take time, but, I promise you, you will get over this depression." D. "Every client who has this surgery feels the same way for about a month." - Correct answer A. "Tell me more about what you're feeling." 7 A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse's priority? A. Contacting the physician B. Documenting the findings C. Checking the fluid for protein D. Continuing to monitor the client and the FHR - Correct answer A. Contacting the physician Correct 8 A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to: A. Call the radiography department to obtain a chest x-ray B. Check the client's blood glucose level to serve as a baseline measurement C. Hang the prescribed bag of PN and start the infusion at the prescribed rate D. Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency - Correct answer A. Call the radiography department to obtain a chest x-ray 9 A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the appropriate response by the nurse? A. "HIV is rarely an issue in rape victims."
15 Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing physician before administering the medication? A. The client has a history of cataracts. B. The client has a history of hypothyroidism. C. The client takes a prescribed antihypertensive. D. The client is allergic to acetylsalicylic acid (aspirin). - Correct answer C. The client takes a prescribed antihypertensive. 16 A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which of the following findings does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client? A. Fever B. Diarrhea C. Hypertension D. Tongue protrusion - Correct answer D. Tongue protrusion 17 A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client's record, would indicate a need to contact the physician who is scheduled to perform the ECT? A. Recent stroke B. Hypothyroidism C. History of glaucoma D. Peripheral vascular disease - Correct answer A. Recent stroke 18 A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through: A. A lower abdominal incision B. An upper abdominal incision C. An incision made in the perineal area D. The urethra, with the use of a cutting wire - Correct answer A. A lower abdominal incision 19 A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply. A. Seek medical advice if you find a skin lesion. B. Use sunscreen with a low sun protection factor (SPF). C. Avoid sun exposure before 10 a.m. and after 4 p.m. D. Wear a hat, opaque clothing, and sunglasses when out in the sun. E. Examine the body every 6 months for possibly cancerous or precancerous lesions. - Correct answer A. Seek medical advice if you find a skin lesion.
D. Wear a hat, opaque clothing, and sunglasses when out in the sun. 20 A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast? SEE PICS A. B. C. D. - Correct answer B. Correct 21 The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother: A. To always administer less insulin on the days of soccer games B. That it is best not to encourage the child to participate in sports activities C. That the child should eat a carbohydrate snack about a half-hour before each soccer game D. To administer additional insulin before a soccer game if the blood glucose level is 240 mg/dL or higher and ketones are present
- Correct answer C. That the child should eat a carbohydrate snack about a half-hour before each soccer game 22 A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? A. Anxiety B. Powerlessness C. Ineffective coping D. Disturbed body image - Correct answer B. Powerlessness 23 A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic? A. "What are your feelings right now?" B. "Why don't you feel like washing up?" C. "You aren't talking today. Cat got your tongue?" D. "You need to get yourself cleaned up. You have company coming today." - Correct answer A. "What are your feelings right now?" 24 Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the physician with the procedure, expect to note? A. Clear and yellow B. Thick and opaque
A. Bradycardia B. Increased heart rate C. Decreased blood pressure D. Improved swallowing function - Correct answer D. Improved swallowing function 31 A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication? A. Insomnia B. Rigidity and akinesia C. Bilateral lung wheezes D. Orthostatic hypotension - Correct answer C. Bilateral lung wheezes 32 A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet?Select all that apply. A. Smoking Correct B. A high-calcium diet C. High alcohol intake Correct D. White or Asian ethnicity Correct E. Participation in physical activities that promote flexibility and muscle strength - Correct answer A. Smoking Correct C. High alcohol intake Correct D. White or Asian ethnicity Correct 33 A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is: A. Corn B. Cocoa C. Peaches D. Sardines - Correct answer D. Sardines 34 A nurse is providing information to a client with acute gout about home care. Which of the following measures does the nurse tell the client to take? Select all that apply. A. Drinking 2 to 3 L of fluid each day B. Applying heat packs to the affected joint C. Resting and immobilizing the affected area D. Consuming foods high in purines E. Performing range-of-motion exercise to the affected joint three times a day - Correct answer A. Drinking 2 to 3 L of fluid each day Correct
C. Resting and immobilizing the affected area Correct 35 A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. A. Fatigue B. Anemia C. Weight loss D. Low-grade fever E. Joint deformities - Correct answer A. Fatigue Correct D. Low-grade fever Correct 36 A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply. A. Fever B. Vasculitis C. Weight gain D. Increased energy E. Abdominal pain - Correct answer A. Fever Correct B. Vasculitis Correct E. Abdominal pain Correct 37 A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply. A. Beer B. Apples C. Yogurt D. Baked haddock E. Pickled herring F. Roasted fresh potatoes - Correct answer A. Beer Correct C. Yogurt Correct E. Pickled herring Correct 38 The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should: A. Contact the physician B. Hold the next dose of imipramine C. Document the laboratory result in the client's record
C. Decreased fluid volume D. Inability to tolerate activity - Correct answer C. Decreased fluid volume 44 A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine: A. The sex of the fetus B. Genetic characteristics C. An accurate age for the fetus D. The degree of fetal lung maturity - Correct answer D. The degree of fetal lung maturity 45 A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply. A. Bananas B. Potatoes C. Spinach D. Legumes E. Whole grains F. Milk products - Correct answer C. Spinach Correct D. Legumes Correct E. Whole grains Correct 46 A nurse caring for a client with pre-eclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside? A. Vitamin K B. Protamine sulfate C. Potassium chloride D. Calcium gluconate - Correct answer D. Calcium gluconate 47 A nurse is monitoring a client receiving terbutaline (Brethine) by intravenous infusion to stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by the nurse is: A. Contacting the physician B. Documenting the findings C. Continuing to monitor the client D. Increasing the rate of the infusion - Correct answer A. Contacting the physician 48 A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that: A. Sodium intake is restricted B. Fluid intake must be limited to 1 quart each day
C. Urine output must be measured and that the physician should be notified if output is less than 500 mL in a 24 - hour period D. Urinary protein must be measured and that the physician should be notified if the results indicate a trace amount of protein - Correct answer C. Urine output must be measured and that the physician should be notified if output is less than 500 mL in a 24 - hour period 49 A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which items of the following information elicited during the assessment indicate that the condition has not yet resolved? Type the option number that is the correct answer.
- Correct answer Answer: __ Correct Responses: "1"____ Nursing Progress Notes
- Hyperreflexia is present.
- Urinary protein is not detectable.
- Urine output is 45 mL/hr.
- Blood pressure is 128/78 mm Hg. 50 A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client? A. Spontaneous bruising B. Decrease in uterine size C. Urine output of 30 mL/hr D. Brownish vaginal discharge - Correct answer A. Spontaneous bruising 51 A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately: A. Stops the oxytocin infusion Correct B. Checks the vagina for crowning C. Encourages the client to take short, deep breaths D. Increases the rate of the oxytocin infusion and calls the physician - Correct answer A. Stops the oxytocin infusion 52 A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which of the following actions should the nurse take as a result of this observation? A. Repositioning the mother B. Documenting the finding Correct C. Notifying the nurse-midwife D. Taking the mother's vital signs - Correct answer B. Documenting the finding 53 A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client? A. Nausea B. Bloody urine C. Hearing loss
F. A respiratory rate of 18 breaths/min - Correct answer A. Skin tenting Correct B. Flat neck veins Correct C. Weak peripheral pulses Correct 59 An adult client with renal failure who is oliguric and undergoing hemodialysis is under a fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have between 7 a.m. and 3 p.m.?Type your answer in the space provided. Answer ____mL - Correct answer Correct Responses: "350" 60 A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use: A. Salt substitutes B. Herbs and spices C. Salt with cooking only D. Processed foods as desired - Correct answer B. Herbs and spices 61 A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse that the client understands the instructions? A. Coffee B. Broccoli C. Cheeseburger D. Chocolate milk - Correct answer C. Cheeseburger 62 Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client? A. Headache B. Drowsiness C. Photophobia D. Urinary frequency - Correct answer B. Drowsiness 63 A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client? A. Diarrhea B. Vomiting C. Epistaxis D. Epigastric pain - Correct answer C. Epistaxis 64 A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk?
A. Count the number of times that the infant swallows during a feeding B. Weigh the infant every day and check for a daily weight gain of 2 oz C. Count wet diapers to be sure that the infant is having at least six to 10 each day D. Pump the breasts, place the milk in a bottle, measure the amount, and then bottle-feed the infant - Correct answer C. Count wet diapers to be sure that the infant is having at least six to 10 each day 65 A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information? A. "My child will need to do exercises." B. "My child needs to wear the brace 18 to 23 hours per day." C. "Wearing the brace is really important in curing the scoliosis." D. "I need to check my child's skin under the brace to be sure it doesn't break down." - Correct answer C. "Wearing the brace is really important in curing the scoliosis." 66 Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with: A. Milk B. Water C. Any meal D. Tomato juice - Correct answer D. Tomato juice 67 A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally: A. Increase B. Decrease C. Remain unchanged D. Double from what they normally are - Correct answer B. Decrease 68 A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that: A. No edema is present B. The client is dehydrated C. Pitting edema is present D. Blood is not pooling in the extremities - Correct answer C. Pitting edema is present 69 A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would: A. Contact the physician B. Document the findings
C. Positive result on d-dimer study D. Decreased fibrin-degradation products - Correct answer C. Positive result on d-dimer study 75 - A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply. A. Tachycardia Correct B. Cool, clammy skin C. Decreased respiratory rate D. Diminished peripheral pulses Correct E. Urine output of less than 30 mL/hr - Correct answer A. Tachycardia Correct D. Diminished peripheral pulses Correct 76 - A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock? A. Checking the client's urine output B. Inserting an intravenous (IV) line C. Obtaining informed consent for a cesarean delivery D. Placing the client in a lateral position with the bed flat - Correct answer D. Placing the client in a lateral position with the bed flat 77 - A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician? A. Pink lochia on postpartum day 4 B. White lochia on postpartum day 11 C. Bloody lochia on postpartum day 2 D. Reddish lochia on postpartum day 8 - Correct answer D. Reddish lochia on postpartum day 8 78 A nurse in a physician's office is conducting a 2 - week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to: A. Document the findings B. Ask the physician to see the client immediately C. Ask another nurse to check for the uterine fundus D. Place the client in the supine position for 5 minutes, then recheck the abdome - Correct answer A. Document the findings 79 - A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta? A. "Many of my antibodies are passed through the placenta." B. "The placenta maintains the body temperature of my baby."
C. "Glucose, vitamins, and electrolytes pass through the placenta." D. "It provides an exchange of oxygen and carbon dioxide between me and my baby." - Correct answer B. "The placenta maintains the body temperature of my baby." 80 - A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is: A. June 2, 2013 B. July 2, 2013 C. October 2, 2013 D. September 18, 2013 - Correct answer B. July 2, 2013 81 A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication? A. Steak B. Spinach C. Chicken D. Oranges - Correct answer A. Steak 82 - A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy? A. Sodium 140 mEq/L B. Hemoglobin 12.5 g/dL C. Blood urea nitrogen (BUN) 20 mg/dL D. White blood cell count of 2500 cells/mm3 - Correct answer D. White blood cell count of 2500 cells/mm 83 - Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse? A. Nulliparity B. Early menarche C. Multiple sexual partners Correct D. Hormone-replacement therapy - Correct answer C. Multiple sexual partners 84 - A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding? A. Umbilical cord compression B. Pressure on the fetal head during a contraction C. Uteroplacental insufficiency during a contraction Correct D. Inadequate pacemaker activity of the fetal heart - Correct answer C. Uteroplacental insufficiency during a contraction
SEE PIC
A.
B.
C.
D. - Correct answer D. 91 - Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply A. Keeping the room slightly darkened B. Placing the client in a room with a quiet roommate C. Encouraging isometric exercises if bed rest is prescribed D. Monitoring the client for changes in alertness or mental status E. Restricting visits to close family members and significant others and keeping visits short - Correct answer A. Keeping the room slightly darkened Correct D. Monitoring the client for changes in alertness or mental status Correct E. Restricting visits to close family members and significant others and keeping visits short Correct 92 - A nurse, providing information to a client who has just been found to have diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply. A. Hunger B. Weakness C. Blurred vision D. Increased thirst E. Increased urine output - Correct answer A. Hunger Correct B. Weakness Correct C. Blurred vision Correct 93 - A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the physician's instructions, understanding that the gait was selected after assessment of the client's: A. Physical and functional abilities B. Feelings about restricted mobility C. Uneasiness about using the crutches D. Understanding of the need for increased mobility - Correct answer A. Physical and functional abilities 94 - A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral tube feedings that will be continued after he is discharged home. When the nurse tells the client that he will be taught how to administer the feedings, the client states, "I don't think I'll be able to do these feedings by myself." Which response by the nurse is appropriate?
A. "Have you told your doctor how you feel?" B. "Tell me more about your concerns regarding the tube feedings." C. "Don't worry. We'll keep you in the hospital until you're ready to do them by yourself." D. "We'll ask the doctor about having a visiting nurse come to your home to give you your feedings." - Correct answer B. "Tell me more about your concerns regarding the tube feedings." 95 - A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis of the ABG result, the nurse prepares to: A. Continue monitoring the client B. Increase the amount of humidified oxygen C. Continue administering humidified oxygen D. Assist in intubating the client and beginning mechanical ventilation - Correct answer D. Assist in intubating the client and beginning mechanical ventilation 96 - A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which of the following actions should the nurse take next? A. Providing pin care B. Medicating the client C. Notifying the physician Correct D. Removing some weight from the traction - Correct answer C. Notifying the physician 97 - A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse A. Bivalve the cast B. Ask the physician to reapply the cast C. Use a nail file to smooth the rough edges D. Place small pieces of tape over the rough edges of the cast - Correct answer D. Place small pieces of tape over the rough edges of the cast 98 - A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it's probably cancer. Does this mean I'm going to die?" The nurse interprets the client's initial reaction as: A. Fear B. Denial C. Acceptance D. Preoccupation with self - Correct answer A. Fear 99 - A nurse notes documentation in the client's medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which of the following findings does the nurse expect to note?
