Download HESI EXAM 1 QUESTIONS WITH VERIFIED ANSWERS 2025 and more Exams Nursing in PDF only on Docsity!
HESI EXAM 1 QUESTIONS WITH VERIFIED ANSWERS 2025
A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. the child smells of chemicals on the hands, face, and on the front of the child's clothes. after ensuring the airway is patent, what action should the nurse implement first? a. Assess the child for altered sensorium b. Determine type of chemical exposure c. Obtain equipment for gastric lavage d. Call poison control emergency number - Correct answer b. Determine type of chemical exposure Which conditions are most likely to respond to treatment with antihistamines? Select all that apply. a. Bronchitis b. Allergic rhinitis c. Otitis media d. Contact dermatitis e. Myocarditis - Correct answer b. Allergic rhinitis d. Contact dermatitis An older client's daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days ago and is now getting worse. Which action should the nurse take? Select all that apply. a. Ask if the mother is experiencing any pain with urination b. Encourage increased intake of high protein foods c. Instruct the daughter to check her mother's temperature d. Review the client's current food and medication allergies e. Determine if the mother has recently experienced a fall - Correct answer a. Ask if the mother is experiencing any pain with urination c. Instruct the daughter to check her mother's temperature e. Determine if the mother has recently experienced a fall The nurse is assessing a male with a history of Addison's disease. The client has flu-like symptoms and nausea with vomiting over the past week. The client's spouse reports that he acted confused and was extremely weak when he awoke this morning. The client is febrile and has tachycardia. The health care provider diagnoses acute adrenal insufficiency. Which medication will most likely be prescribed? a. Hypertonic saline solution at 100 ml/hr until all edema disappears b. Hydrocortisone 100 mg IV every six hours until systolic BP reaches 110 mmHg c. Potassium chloride 20 mEq IV to infuse over 2 hours until confusion resolves d. Regular insulin drip to keep blood glucose around 100 mg/dl (5.55 mmol/L) - Correct answer b. Hydrocortisone 100 mg IV every six hours until systolic BP reaches 110 mmHg A client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion, and is diagnosed with acute infective endocarditis. During the admission assessment, the nurse observes multiple areas of petechiae on the client's skin. Which intervention should the nurse include in the client's plan of care? Select all that apply.
a. Monitor cardiac rhythm via telemetry b. Report changes in pre-existing murmurs c. Schedule rest periods between activities d. Maintain record of fluid intake and output e. Initiate contact transmission precautions - Correct answer a. Monitor cardiac rhythm via telemetry b. Report changes in pre-existing murmurs e. Initiate contact transmission precautions The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome (SIDS). Which information is most important to provide parents of newborns and infants? a. Remove pillows and soft toys from the crib at bedtime b. Keep a bulb syringe accessible for use for an infant c. Position the infant in a supine position while sleeping d. Do not prop bottles for an infant during naps and bedtime - Correct answer c. Position the infant in a supine position while sleeping The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What findings should indicate to the nurse to withhold the next dose of medication? a. Hypertension b. Difficulty locating the uterine fundus c. Saturation of more than one pad per hour d. Excessive lochia - Correct answer a. Hypertension The nurse notes that an older adult client has a moist cough that increases in severity during and after meals. Based on this finding, which action should the nurse take? a. Collect a sputum specimen immediately b. Request a consultation to confirm dysphasia c. Offer the client additional clear liquids frequently d. Encourage the client to do deep breathing exercises daily - Correct answer b. Request a consultation to confirm dysphasia A multiparous client who delivered her infant 3 hours ago asks the nurse if she can take a warm sitz bath because it helped reduce perennial pain after her last delivery. What action should the nurse implement? a. Using analgesic spray to the perennial area to reduce pain b. Apply an ice pack to the perineum for the first 24 hours c. Teach the client how to practice kegel exercises d. Review the use of sitz bath equipment with the client - Correct answer d. Review the use of sitz bath equipment with the client When the parents of a 6 - year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we sought treatment sooner!" Which intervention is best for the nurse to implement? a. Refer the parents to the chaplain to provide grief counseling b. Assure the parents that a terminal diagnosis was inevitable
An older client is admitted in respiratory distress secondary to heart failure (HF), coronary artery disease (CAD), hypertension (HTN), and atrial fibrillation. Which nursing problem should the nurse include in the client's plan of care? Select all that apply. a. Fluid volume excess b. Decreased cardiac output c. Altered peripheral tissue perfusion d. Fluid volume deficit e. Fatigue - Correct answer a. Fluid volume excess b. Decreased cardiac output c. Altered peripheral tissue perfusion e. Fatigue The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? a. As the burn heels, the graft permanently attaches b. Graphs are later removed by a debriding procedure c. Grafting increases the risk for bacterial infections d. The xenograft is taken from non-human sources - Correct answer d. The xenograft is taken from non-human sources A client is admitted with a severe asthma attack. For the last three hours the client has experienced increasing shortness of breath. Arterial blood gas results are: ph 7.22; paco2 55mmhg; HCO3 25 meq/L (25 mmol/L). Which intervention should the nurse implement? a. Space care to provide periods of rest b. Instruct client to purse lip breathe c. Position client for maximum comfort d. Administer PRN dose of albuterol - Correct answer d. Administer PRN dose of albuterol After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? Select all that apply. a. Take out dentures and place in a labeled cup b. Apply a body shroud c. Place a small pillow under the head d. Remove resuscitation equipment from the room e. Gently close the eyes - Correct answer c. Place a small pillow under the head d. Remove resuscitation equipment from the room e. Gently close the eyes The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life- threatening and should be reported to the healthcare provider immediately? a. Facial numbness b. Right ear hearing loss
c. Difficulty with balance d. Intensifying headache - Correct answer d. Intensifying headache When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? Select all that apply. a. Weeping serosanguinous fluid from wounds b. Sloughing tissue around wound edges c. Change in the quality of peripheral pulses d. Loss of sensation to the left lower extremity e. Complaint of increased pain and pressure - Correct answer c. Change in the quality of peripheral pulses d. Loss of sensation to the left lower extremity e. Complaint of increased pain and pressure The nurse is providing teaching to a client who has been recently diagnosed with gestational diabetes mellitus. Which complication poses the greatest risk to the fetus if euglycemia is not maintained? a. Cleft palate b. Preterm birth c. Low birth weight d. Macrosomic newborn - Correct answer b. Preterm birth A female client who has borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that, "My favorite nurses on duty now." Which response is best for the nurse to provide to this clients dichotomous tendency? a. Tomorrow I will talk to that nurse about how you were treated last night b. I am happy that you are getting better and will be able to go home c. I am glad you like me. Which nurse was acting aloof to you? d. What did the night nurse do that makes you think she is aloof? - Correct answer b. I am happy that you are getting better and will be able to go home The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis? a. Decrease in the appetite b. Weight of 227 pounds (103 kg) c. Dry mucosal membranes d. Body mass index (BMI) of 17 - Correct answer d. Body mass index (BMI) of 17 The nurse is preparing a client who had a below the knee amputation for discharge to home. Which recommendation should the nurse provide this client? Select all that apply. a. Avoid range of motion exercises b. Use a residual limb shrinker c. Watch the stump with soap and water d. Inspect skin for redness
a. Restrict daily fluid intake to 1500 ml b. Administer prescribed diuretic c. Maintain accurate intake and output d. Weigh client every morning - Correct answer b. Administer prescribed diuretic The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time? a. Risk for infection b. Impaired physical mobility c. Self-care deficit d. Risk for impaired skin integrity - Correct answer a. Risk for infection The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? a. Prepare the client for spinal anesthesia b. Prepare the coach to accompany the client to delivery c. Empty the client's bladder using a straight catheter d. Convey to the client that birth is imminent - Correct answer d. Convey to the client that birth is imminent A client with cirrhosis of the liver is having numerous, liquid, incontinent stools, and continues to be confused. In reviewing the client's laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is most important for the client to receive? a. Furosemide b. Lactulose c. Loperamide d. IV human albumin - Correct answer b. Lactulose After initiating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. What action should the nurse take next? a. Note the presence of an auscultatory gap b. Reinflate the cuff to a higher number c. Reposition the stethoscope over the brachial artery d. Continue with the blood pressure assessment - Correct answer d. Continue with the blood pressure assessment At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client? a. Anticipatory grieving b. Pain (acute) c. Anxiety d. Knowledge deficit - Correct answer c. Anxiety A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?
a. Administer IV atropine b. Defibrillate with one shock c. Give a dose of amiodarone IV d. Prepare for external pacing - Correct answer b. Defibrillate with one shock A recently hired nurse who is in orientation is assigned to the medical unit. The charge nurse observes the new nurse prepare to administer a unit of packed red blood cells as seen in the picture. Which action should the charge nurse take? a. Verify that a 22 - gauge intravenous catheter is used for the transfusion b. Assist the nurse in changing the intravenous tubing attached to the blood c. Tell the nurse to take the clients vital signs and then start the transfusion d. Assume responsibility for the care of the client during the blood transfusion - Correct answer b. Assist the nurse in changing the intravenous tubing attached to the blood The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. What action should the nurse implement? a. Encourage family members to cook meals outdoors and bring the cooked foods inside b. Advise the client to replace cooked foods with a variety of different nutritional supplements c. Assess the clients' mucous membranes and report the findings to the health care provider d. Instruct the client to take an anti-emetic before every meal to prevent excessive vomiting - Correct answer a. Encourage family members to cook meals outdoors and bring the cooked foods inside The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. Which action should the nurse implement? a. Advise the UAP to document the last blood pressure obtained in the client's graphic sheet b. Demonstrate how to palpate the popliteal pulse with a client supine and the knee flexed c. Document why the blood pressure cannot be accurately measured at the present time d. Estimate the blood pressure by assessing the pulse volume of the clients' radial pulses - Correct answer b. Demonstrate how to palpate the popliteal pulse with a client supine and the knee flexed The nurse working in the psychiatric clinic has phone messages from several clients. Which cost should the nurse return first? a. A young man with schizophrenia who wants to stop taking his medications b. The mother of a child who was involved in a physical fight at school today c. A client diagnosed with depression who is experiencing sexual dysfunction d. A family member of a client with dementia who has been missing for five hours - Correct answer d. A family member of a client with dementia who has been missing for five hours A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? a. Chemotherapy b. Immunosuppressive therapy c. Blood transfusions d. Bone marrow transplantation - Correct answer c. Blood transfusions
An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide? A. Tell the client to discuss the medication side effects with the health care provider B. Inform the client that gradual tapering must be used to discontinue the medication C. Remind the client that feeling better is the therapeutic side effect of the medication D. Tell the client that the medication side effects will most likely dissipate overtime - Correct answer A. Tell the client to discuss the medication side effects with the health care provider A mother brings her child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain? a. Frequency that the child uses a rescue inhaler during the week b. Type of allergen exposure or trigger for the current episode c. Type of inhaler the child typically uses on a regular basis d. Last dose and type of rescue inhaler used by the child - Correct answer a. Frequency that the child uses a rescue inhaler during the week The nurse is teaching the parents of a child newly diagnosed with a latex allergy. Which information by the parents indicates the need for further teaching? a. A diet of healthy fruits, such as bananas and Kiwis, are best for the child b. Only foil balloons will be used for the child's birthday party c. Rubber-free toys, such as wooden building blocks, are good choices for the child d. An epinephrine auto-injector will be on hand to treat allergic reactions - Correct answer a. A diet of healthy fruits, such as bananas and Kiwis, are best for the child A client with chronic kidney disease has an arteriovenous (AV) fistula In the left forearm. Which observation by the nurse indicates that the fistula is patent? a. Distended, tortuous veins in the left hand b. Auscultation of a thrill on the left forearm c. The left radial pulses 2+ bounding d. Assessment of a bruit on the left forearm - Correct answer d. Assessment of a bruit on the left forearm A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? a. History of intravenous drug abuse b. Conversion of the client's PPD test from negative to positive c. Current diagnosis of hepatitis B d. Length of time of the exposure to tuberculosis - Correct answer c. Current diagnosis of hepatitis B The nurse instructs and unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned? a. Empty the urinary drainage bag
b. Assess the breath sounds c. Offer the client oral fluids d. Feed the client a snack - Correct answer c. Offer the client oral fluids A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement? a. Check the client's hemoglobin level b. Review the clients current list of medications c. Assess the client for the presence of hemorrhoids d. Administer prescribed PRN anti-emetic - Correct answer b. Review the clients current list of medications A 15 - year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he has difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? a. Advise him to take his own food with him on going to fast food restaurants with his friends b. Encourage him to find activities to do with his friends that do not involve eating c. Assist him in identifying popular fast foods that are within his meal plan for diabetes d. Recommend that he avoid fast food restaurants until he is familiar with his prescribed diet - Correct answer c. Assist him in identifying popular fast foods that are within his meal plan for diabetes A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? Select all that apply. a. Report serum albumin and globulin levels b. Provide diet low in phosphorus c. Increase oral fluid intake to 1500 ml daily d. Note signs of swelling and edema e. Monitor abdominal girth - Correct answer a. Report serum albumin and globulin levels d. Note signs of swelling and edema e. Monitor abdominal girth The nurse request a food tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? Select all that apply. a. Chicken broth b. Apple juice c. Hot chocolate d. Black coffee e. Orange juice - Correct answer a. Chicken broth b. Apple juice An older client arrives to the emergency department with reports of severe nausea and vomiting large amounts of liquid brown emesis at home. The client's vital signs are temperature of 95.4 degrees F, heart rate 112 beats/minute, respiration 14 breaths/minute, and blood pressure 74/37 mmhg. Which intervention is most important for the nurse to implement? a. Maintain strict intake and output
What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)? a. Obtain adequate rest and sleep b. Reduce risk for infection c. Improve stress management skills d. Achieve satisfactory pain control - Correct answer d. Achieve satisfactory pain control What might the nurse suggest to a client with fibrocystic breasts in the attempt to help relieve her symptoms? a. "Increase high calcium foods in your diet b. "Eat a low carbohydrate, high protein diet" c. "Eliminate caffeine from your diet" d. "Avoid vigorous physical exercise immediately after your menstrual period" - Correct answer c. "Eliminate caffeine from your diet" Client with end stage renal disease (ESRD) is refusing all treatment and requests that no life saving measures be implemented. The health care provider refuses to write do not resuscitate instructions. Which action should the nurse take? a. Initiate a review of the situation by the hospital's ethics committee b. Remind the client that new treatments are being developed daily c. Facilitate a palliative care meeting with the client and health care provider d. Provide the health care provider with a copy of the clients Bill of Rights - Correct answer d. Provide the health care provider with a copy of the clients Bill of Rights A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. Vital signs are: temperature 99.6 degrees F, Heart rate 98 beats/minute, respirations 28 breaths/minute, blood pressure 140/82 mmHg and oxygen saturation 88%. Which action should the nurse implement? a. Prepare client for endotracheal intubation b. Place the client in a forward-leaning position c. Apply a non-rebreather mask at 100% oxygen d. Obtain a sputum sample for culture and sensitivity - Correct answer a. Prepare client for endotracheal intubation A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations for the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply. a. A bedside commode is positioned near the bed b. A full pitcher of water is on the bedside table c. A low sodium diet tray was brought to the room d. The client is lying in the supine position in bed e. A saline lock is present in the right forearm - Correct answer b. A full pitcher of water is on the bedside table d. The client is lying in the supine position in bed A newly hired unlicensed assisted personnel (UAP) is assigned to a home health care team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients? a. Evaluate the newly hired UAP's level of competency by observing the UAP deliver care b. Assign the newly hired UAP to clients who require the least complex level of care
c. Ask the most experienced UAP on the team to partner with the newly hired UAP d. Review the UAP's skills checklist and experience with the person who hired the UAP - Correct answer a. Evaluate the newly hired UAP's level of competency by observing the UAP deliver care The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which finding should the nurse include as indicators to begin implementing the detoxification medication protocol? a. Excessive eating, constipation, headache b. Nausea, vomiting, diaphoresis, anxiety, tremors c. Dilated pupils, tachycardia, elevated blood pressure, elation d. Mood lability, poor hand coordination, fever, drowsiness - Correct answer c. Dilated pupils, tachycardia, elevated blood pressure, elation At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on the data contained in the record, what action should the nurse take before assisting the client with ambulation? a. Remove sequential compression devices b. Apply PRN oxygen per nasal cannula c. Reinforce the surgical wound dressing d. Administer a PRN dose of an antipyretic - Correct answer c. Reinforce the surgical wound dressing Following morning care, a client with a C5 spinal cord injury who is sitting in a wheelchair becomes flushed and complaints of a headache. Which intervention should the nurse implement first? a. Teach the client to recognize symptoms of dysreflexia b. Relieve any kinks or obstruction in the client's Foley tubing c. Administer or prescribe PRN dose of hydralazine d. Assess the client's blood pressures every 15 minutes - Correct answer b. Relieve any kinks or obstruction in the client's Foley tubing An adult woman who was recently diagnosed with type 2 diabetes mellitus (DM) is seen in the clinic for laboratory tests. The client's height is 5 feet 2 inches and weight is 165 pounds. Her recent laboratory findings are described above. In planning nutrition teaching for this client, what diet modification should the nurse recommend? Select all that apply. a. Reduce daily fat intake to 10% of total calories b. Increase dietary fiber such as whole grains c. Decrease processed carbohydrate in diet d. Eliminate alcohol intake except for special occasions e. Restrict protein to 10% of total calories in diet - Correct answer b. Increase dietary fiber such as whole grains c. Decrease processed carbohydrate in diet d. Eliminate alcohol intake except for special occasions A school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow up. The teacher should be instructed to report which situations to the school nurse? Select all that apply. a. Thirst and frequent requests for bathroom breaks b. Shaking that changes the child's handwriting legibility
Dopamine 5 mcg/kg/minute IV is prescribed for a client who weighs 132 pounds. The pharmacy dispenses of 500 ml IV solution of 0.9% normal saline with dopamine 1600 mg. The nurse should program the infusion pump to deliver how many ml/hr? - Correct answer 5. During discharge teaching, and overweight client with heart failure is asked to make a grocery list for the nurse to review period which food choices included in the clients less should the nurse encourage? Select all that apply. a. Natural whole almonds b. Cheddar cheese cubes c. Lightly salted potato chips d. Plain, air-popped popcorn e. Canned fruit in heavy syrup - Correct answer a. Natural whole almonds d. Plain, air-popped popcorn The husband of an older woman, diagnosed with pernicious anemia calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she may be getting Alzheimer's disease. What action should the nurse take? a. Encourage the husband to bring the client to the clinic for a complete blood count b. Determine if the client is taking iron and folic acid supplements c. Explain that memory loss and confusion are common with vitamin B12 deficiency d. Ask if the client is experiencing any change in bowel habits - Correct answer c. Explain that memory loss and confusion are common with vitamin B12 deficiency The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity? a. Aerobic exercise b. Weight bearing exercise c. Muscle stretching and toning d. Core strengthening - Correct answer b. Weight bearing exercise A nurse who was working in the emergency department triage area is presented with four clients at the same time. The client presenting with which symptoms requires the most immediate intervention by the nurse? a. Low grade fever, headache, and malaise for the past 72 hours b. One inch bleeding laceration on the chin of a crying 5 year old c. Chest discomfort one hour after consuming a large, spicy meal d. Unable to bear weight on the left foot, with swelling and bruising - Correct answer c. Chest discomfort one hour after consuming a large, spicy meal Which assessment finding is most important when planning to provide a complete bed bath to a bed fast client? a. Right sided paralysis b. 2+ pitting edema of the feet c. Pallor d. Orthopnea - Correct answer d. Orthopnea
A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. Which intervention should the nurse include in this clients plan of care? a. Teach techniques for scanning the environment b. Encourage the use of corrective lenses during the day c. Alternate an eye patch from eye to eye every two hours d. Practice visual exercises that focus on a still object - Correct answer a. Teach techniques for scanning the environment The nurse should expect a client diagnosed with regional enteritis (Crohn's disease) to exhibit which initial symptoms? a. Rigid board like abdomen and elevated white blood cell count b. Dull, left lower cramping pain and a low-grade fever c. Diarrhea, abdominal pain, and weight loss d. Change in bowel habits, blood and stool, and unexplained anemia - Correct answer c. Diarrhea, abdominal pain, and weight loss A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? a. Erythrocyte sedimentation rate b. Serum calcium c. Osmolality d. Hemoglobin - Correct answer d. Hemoglobin Which class of drugs is the only source of cure for septic shock? a. Anticholesteremics b. Antihypertensives c. Antiinfectives d. Antihistamines - Correct answer c. Antiinfectives An infant is unresponsive and gasping for breath period prior to starting CPR, which site should the nurse palpate for a pulse? - Correct answer Brachial The nurse is caring for a client who reports experiencing pain. The client reads the pain as two out of 10 on the numeric 1 - 10 pain scale. Which prescription should the nurse administer? a. Acetaminophen b. Hydrocodone c. Ketorolac d. Morphine sulfate - Correct answer a. Acetaminophen After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the X-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? a. Initiate intravenous fluids as prescribed b. Remove the catheter and apply direct pressure for five minutes c. Notify the health care provider of the need to reposition the catheter
A male client with a fracture of the left femur has skeletal traction in place while waiting for surgery. The client is restless and tells the nurse that he needs to urgently urinate. What intervention should the nurse implement? a. Log roll and place adult disposable briefs b. Insert an indwelling urinary catheter c. Maintain traction while client uses the urinal d. Release traction so client can use bedpan - Correct answer b. Insert an indwelling urinary catheter A male client who was in a motor vehicle collision yesterday is receiving a unit of packed red blood cells. When half of the unit is infused, the client reports lower back pain, and the nurse observes a fine rash over the chest and back. Which intervention should the nurse implement? a. Apply an anti-itch ointment over the rash area b. Instruct the client to avoid lying on his back c. Administer scheduled dose of glucocorticoid d. Replace the transfusion with normal saline - Correct answer d. Replace the transfusion with normal saline After years of struggling with weight management, a middle-aged man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but has it's been approved for surgery. Which intervention is most important for the nurse to include in this client plan of care? a. Observed for signs of depression b. Monitor for urinary incontinence c. Provide a wide variety of meal choices d. Apply sequential compression stockings - Correct answer d. Apply sequential compression stockings The healthcare provider prescribes ceftazidime 1 gram every 8 hours. The label on the 1 gram vial reads, "reconstitute with 100ml sterile water." This dilution provides a concentration of how many mg/ml? - Correct answer 10 The nurse is preparing to administer 1.6 ml of medication intramuscularly to a four-month-old infant. Which action should the nurse include? a. Is a quick dart like motion to inject into the dorsogluteal site b. Divide the medication into two injections with volumes under 1 ml c. Administer into the deltoid muscle while the parent holds the infant securely d. Select a 22 gauge 1 ½ inch (3.8 cm) needle for the intramuscular injection - Correct answer b. Divide the medication into two injections with volumes under 1 ml The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? a. Case management and screening for clients with HIV b. Regional relocation Center for earthquake victims c. Lead screening for children in low-income housing d. Vitamin supplements for high-risk pregnant women - Correct answer d. Vitamin supplements for high-risk pregnant women When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room period which action should the nurse take?
a. Encourage the client to implement relaxation techniques b. Explain that insulin is a lifesaving drug for the client c. Refer the client to a social worker for support therapy d. Leave their clients room and return later in the day - Correct answer d. Leave their clients room and return later in the day The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. What is the priority nursing action? a. Determine why the UAP did not notify the nurse of the change in the client's condition b. Advise the UAP stop providing care so the nurse can assess the client's condition c. Explain to the UAP that changes in the client's condition should be reported immediately d. Ask the UAP to position the client so the oral medications can be administered - Correct answer d. Ask the UAP to position the client so the oral medications can be administered An adult male reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is vegetarian, and takes atenolol which maintains his blood pressure at 130/74 mmHg. Which risk factor should the nurse explore further with the client? Select all that apply. a. Family health history b. Homosexual lifestyle c. History of hypertension d. Vegetarian diet e. Excessive aerobic exercise - Correct answer a. Family health history c. History of hypertension An older client returns to the clinic and received refills on several medications. The client shares concerns with the nurse about having to take so many medications and asks if one pill can be substituted for many of the others. Which instruction should the nurse implement to address the clients concerns? A. Do not take any over the counter drugs while taking medications prescribed by the health care provider B. Make certain a family member knows the name and use of all medications currently being taken C. Use a medication reminder system to prevent forgetting to take the right medications at the right time D. Bring all medications, supplements, and herbs currently being taken to the next clinic appointment - Correct answer C. Use a medication reminder system to prevent forgetting to take the right medications at the right time Which laboratory values are critical for the nurse to monitor for a client who is experiencing thyrotoxic crisis? a. Blood in urine cultures b. Glucose and calcium levels c. Renal and liver function tests d. Electrolytes and hemoglobin - Correct answer c. Renal and liver function tests A 46 year old male client who had a myocardial infarction (MI) 24 hours ago comes to the nurses station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?
