HESI RN EXIT Exam Questions and Verified Answers 2024

In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust?

A) Food

B) Warmth

C) Security

D) Comfort

C) Security

A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication?

A) "I cannot give this medication as it is written. I have no idea of what you mean."

B) "Would you please clarify what you have written so I am sure I am reading it

correctly?"

C) "I am having difficulty reading your handwriting. It would save me time if you would be more careful."

D) "Please print in the future so I do not have to spend extra time attempting to read your writing."

B) "Would you please clarify what you have written so I am sure I am reading it

correctly?"

What is the most important consideration when teaching parents how to reduce risks in the home?

A) Age and knowledge level of the parents

B) Proximity to emergency services

C) Number of children in the home

D) Age of children in the home

D) Age of children in the home

A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should

A) Administer a placebo

B) Encourage increased fluid intake

C) Administer the prescribed analgesia

D) Recommend relaxation exercises for pain control

C) Administer the prescribed analgesia

While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention?

A) Respiratory rate of 42

B) Lethargy for the past hour

C) Apical pulse of 54

D) Coughing up copious secretions

A) Respiratory rate of 42

A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings?

A) Lethargy

B) Heat intolerance

C) Diarrhea

D) Skin eruptions

A) Lethargy

The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse?

A) "Do not worry. Epilepsy can be treated with medications."

B) "The seizure may or may not mean your child has epilepsy."

C) "Since this was the first convulsion, it may not happen again."

D) "Long term treatment will prevent future seizures."

B) "The seizure may or may not mean your child has epilepsy."

Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies?

A) Risk for injury

B) Risk for knowledge deficit

C) Altered thought process

D) Disturbance in self-esteem

A) Risk for injury

Which these findings would the nurse more closely associate with anemia in a 10 month-old infant?

A) Hemoglobin level of 12 g/dI

B) Pale mucosa of the eyelids and lips

C) Hypoactivity

D) A heart rate between 140 to 160

B) Pale mucosa of the eyelids and lips

The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is

A) Heart rate

B) Pedal pulses

C) Lung sounds

D) Pupil responses

D) Pupil responses

Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump?

A) A young adult with a history of Down's syndrome

B) A teenager who reads at a 4th grade level

C) An elderly client with numerous arthritic nodules on the hands

D) A preschooler with intermittent episodes of alertness

D) A preschooler with intermittent episodes of alertness

The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be

A) Irritable and "colicky" with no attempts to pull to standing

B) Alert, laughing and playing with a rattle, sitting with support

C) Skin color dusky with poor skin turgor over abdomen

D) Pale, thin arms and legs, uninterested in surroundings

D) Pale, thin arms and legs, uninterested in surroundings

As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion?

A) Mouth sores

B) Fatigue

C) Diarrhea

D) Hair loss

D) Hair loss

While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degreesCelsius). The appropriate nursing intervention is to

A) Call the health care provider immediately

B) Administer acetaminophen as ordered as this is normal at this time

C) Send blood, urine and sputum for culture

D) Increase the client's fluid intake

B) Administer acetaminophen as ordered as this is normal at this time

A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be

A) Cover the areas with dry sterile dressings

B) Assess for dyspnea or stridor

C) Initiate intravenous therapy

D) Administer pain medication

B) Assess for dyspnea or stridor

Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider?

A) I started my period and now my urine has turned bright red.

B) I am an diabetic and today I have been going to the bathroom every hour.

C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom.

D) I went to the bathroom and my urine looked very red and it didn't hurt when I went.

D) I went to the bathroom and my urine looked very red and it didn't hurt when I went.

Which of these parents' comment for a newborn would most likely reveal an initial finding of a suspected pyloric stenosis?

A) I noticed a little lump a little above the belly button.

B) The baby seems hungry all the time.

C) Mild vomiting that progressed to vomiting shooting across the room.

D) Irritation and spitting up immediately after feedings.

C) Mild vomiting that progressed to vomiting shooting across the room.

The nurse is assessing a child for clinical manifestations of iron deficiency anemia.

Which factor would the nurse recognize as cause for the findings?

A) Decreased cardiac output

B) Tissue hypoxia

C) Cerebral edema

D) Reduced oxygen saturation

B) Tissue hypoxia

The nurse would expect the cystic fibrosis client to receive supplemental pancreatic

enzymes along with a diet

A) High in carbohydrates and proteins

B) Low in carbohydrates and proteins

C) High in carbohydrates, low in proteins

D) Low in carbohydrates, high in proteins

A) High in carbohydrates and proteins

In evaluating the growth of a 12 month-old child, which of these findings would the

nurse expect to be present in the infant?

A) Increased 10% in height

B) 2 deciduous teeth

C) Tripled the birth weight

D) Head > chest circumference

C) Tripled the birth weight

A Hispanic client in the postpartum period refuses the hospital food because it is

"cold." The best initial action by the nurse is to

A) 1Have the unlicensed assistive personnel (UAP) reheat the food if the client wishes

B) Ask the client what foods are acceptable or bad

C) Encourage her to eat for healing and strength

D) Schedule the dietitian to meet with the client as soon as possible

B) Ask the client what foods are acceptable or bad

The father of an 8 month-old infant asks the nurse if his infant's vocalizations are

normal for his age. Which of the following would the nurse expect at this age?

A) Cooing

B) Imitation of sounds

C) Throaty sounds

D) Laughter

B) Imitation of sounds

The nurse should recognize that physical dependence is accompanied by what

findings when alcohol consumption is first reduced or ended?

A) Seizures

B) Withdrawal

C) Craving

D) Marked tolerance

B) Withdrawal

Immediately following an acute battering incident in a violent relationship, the

batterer may respond to the partner's injuries by

A) Seeking medical help for the victim's injuries

B) Minimizing the episode and underestimating the victim's injuries

C) Contacting a close friend and asking for help

D) Being very remorseful and assisting the victim with medical care

B) Minimizing the episode and underestimating the victim's injuries

A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago.During the nurse's initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication?

A) "I have a sharp pain in my chest when I take a breath.

"B) "I have been coughing up foul-tasting, brown, thick sputum.

" C) "I have been sweating all day.

"D) "I feel hot off and on."

"B) "I have been coughing up foul-tasting, brown, thick sputum.

The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal

A) S3 ventricular gallop

B) Apical click

C) Systolic murmur

D) Split S2

A) S3 ventricular gallop

Which of these observations made by the nurse during an excretory urogram indicate a complicaton?

A) The client complains of a salty taste in the mouth when the dye is injected

B) The client's entire body turns a bright red color

C) The client states "I have a feeling of getting warm."

D) The client gags and complains " I am getting sick."

B) The client's entire body turns a bright red color

A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?

A) "The tube will drain fluid from your chest.

"B) "The tube will remove excess air from your chest."

C) "The tube controls the amount of air that enters your chest.

" D) "The tube will seal the hole in your lung."

"B) "The tube will remove excess air from your chest."

The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately?

A) Blood urea nitrogen 50 mg/dl

B) Hemoglobin of 10.3 mg/dl

C) Venous blood pH 7.30

D) Serum potassium 6 mEq/L

D) Serum potassium 6 mEq/L

The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention?

A) Pallor

B) Increased temperature

C) Dyspnea

D) Involuntary muscle spasms

C) Dyspnea

The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse?

A) Breath sounds can be heard bilaterally

B) Mist is visible in the T-Piece

C) Pulse oximetry of 88

D) Client is unable to speak

C) Pulse oximetry of 88

A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning?A) Drowsiness

B) Complaint of nausea

C) Pulse rate of 92

D) Restlessness

D) Restlessness

During the evaluation phase for a client, the nurse should focus on

A) All finding of physical and psychosocial stressors of the client and in the family

B) The client's status, progress toward goal achievement, and ongoing re-evaluation

C) Setting short and long-term goals to insure continuity of care from hospital to home

D) Select interventions that are measurable and achievable within selected timeframes

B) The client's status, progress toward goal achievement, and ongoing re-evaluation

The school nurse suspects that a third grade child might have Attention Deficit Hyperactivity Disorder. Prior to referring the child for further evaluation, the nurse should

A) Observe the child's behavior on at least 2 occasions

B) Consult with the teacher about how to control impulsivity

C) Compile a history of behavior patterns and developmental accomplishments

D) Compare the child's behavior with classic signs and symptoms

C) Compile a history of behavior patterns and developmental accomplishments

Which of the actions suggested to the RN by the PN during a planning conference for a 10 month-old infant admitted 2 hours ago with bacterial meningitis would be acceptable to add to the plan of care?

A) Measure head circumference

B) Place in airborne isolation

C) Provide passive range of motion

D) Provide an over-the-crib protective top

A) Measure head circumference

A client is admitted with a diagnosis of hepatitis B. In reviewing the initial laboratory

results, the nurse would expect to find elevation in which of the following values?

A) Blood urea nitrogen

B) Acid phosphatase

C) Bilirubin

D) Sedimentation Rate

C) Bilirubin

The nurse is discussing nutritional requirements with the parents of an 18 month-old

child. Which of these statements about milk consumption is correct?

A) May drink as much milk as desired

B) Can have milk mixed with other foods

C) Will benefit from fat-free cow's milk

D) Should be limited to 3-4 cups of milk daily

D) Should be limited to 3-4 cups of milk daily

The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client's behavior most likely indicates

A) Neologisms

B) Dissociation

C) Flight of ideas

D) Word salad

C) Flight of ideas

A mother asks about expected motor skills for a 3 year-old child. Which of the

following would the nurse emphasize as normal at this age? A) Jumping rope

B) Tying shoelaces

C) Riding a tricycle

D) Playing hopscotch

C) Riding a tricycle

A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is

A) A transparent film dressing

B) Wet dressing with debridement granules

C) Wet to dry with hydrogen peroxide

D) Moist saline dressing

D) Moist saline dressing

The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is asked if he is ready to take his medicine, he immediately says, "No!" What would be the most appropriate next action?

A) Leave the room and return five minutes later and give the medicine

B) Explain to the child that the medicine must be taken now C) Give the medication to the father and ask him to give it

D) Mix the medication with ice cream or applesauce

A) Leave the room and return five minutes later and give the medicine

A nurse is doing pre conceptual counseling with a woman who is planning a pregnancy. Which of the following statements suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?

A) "I understand that a glass of wine with dinner is healthy.

"B) "Beer is not really hard alcohol, so I guess I can drink some.

"C) "If I drink, my baby may be harmed before I know I am pregnant.

" D) "Drinking with meals reduces the effects of alcohol."

"C) "If I drink, my baby may be harmed before I know I am pregnant.

A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?

A) Increased blood pressure

B) Increased heart rate

C) Loss of pulse in the extremity

D) Decreased urine output

C) Loss of pulse in the extremity

A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago.He received 1000 mL of IV fluid. Which action would be most likely to help him void?

A) Have him drink several glasses of water

B) Crede' the bladder from the bottom to the top

C) Assist him to stand by the side of the bed to void

D) Wait 2 hours and have him try to void again

C) Assist him to stand by the side of the bed to void

The nurse is caring for a client who requires a mechanical ventilator for breathing.The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

A) Disconnect the client from the ventilator and use a manual resuscitation bag

B) Perform a quick assessment of the client's condition

C) Call the respiratory therapist for help

D) Press the alarm re-set button on the ventilator

B) Perform a quick assessment of the client's condition

The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test?

A) "I can't lie in 1 position for more than thirty minutes.

"B) "I am allergic to shrimp."

C) "I suffer from claustrophobia.

"D) "I developed a severe headache after a spinal tap."

"B) "I am allergic to shrimp."

The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take?

A) Hold the tube feeding and notify the provider

B) Administer the tube feeding as scheduled

C) Irrigate the tube with diet cola soda

D) Apply intermittent suction to the feeding tube

A) Hold the tube feeding and notify the provider

To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must

A) Apply suction for no more than 10 seconds

B) Maintain sterile technique

C) Lubricate 3 to 4 inches of the catheter tip

D) Withdraw catheter in a circular motion

A) Apply suction for no more than 10 seconds

An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to

A) Administer the medication in 2 separate injections

B) Give the medication in the dorsal gluteal site

C) Call to get a smaller volume ordered

D) Check with pharmacy for a liquid form of the medication skip

A) Administer the medication in 2 separate injections

The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to

A) Enhance absorption of the medication

B) Ensure that the entire dose of medication is given

C) Provide more even distribution of the drug

D) Prevent the drug from tissue irritation Skip

D) Prevent the drug from tissue irritation Skip

A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug?

A) Diaphoresis with decreased urinary output

B) Increased heart rate with increase respirations

C) Improved respiratory status and increased urinary output D) Decreased chest pain and decreased blood pressure

C) Improved respiratory status and increased urinary output

While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?

A) "As you urinate more, you will need less medication to control fluid.

"B) "You will have to take this medication for about a year."

C) "The medication must be continued so the fluid problem is controlled.

"D) "Please talk to your health care provider about medications and treatments."

C) "The medication must be continued so the fluid problem is controlled.

A client is being discharged with a prescription for chlorpromazine (Thorazine).Before leaving for home, which of these findings should the nurse teach the client to report? A) Change in libido, breast enlargement

B) Sore throat, fever

C) Abdominal pain, nausea, diarrhea

D) Dsypnea, nasal congestion

B) Sore throat, fever

A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first?

A. Cleanse the foot with soap and water and apply an antibiotic ointment

B. Provide teaching about the need for a tetanus booster within the next 72 hours.

C. have the mother check the child's temperature q4h for the next 24 hours

D. transfer the child to the emergency department to receive a gamma globulin

injection

A. Cleanse the foot with soap and water and apply an antibiotic ointment

A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences:

A. Bradycardia and constipation

B. Lethargy and lack of appetite

C. Muscle cramping and dry, flushed skin

D. Palpitations and shortness of breath

D. Palpitations and shortness of breath

A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client?

Obtain a list of medications taken for cardiac history

The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply)

A. Fluid shifts from intravascular to interstitial area due to decreased serum

protein

B. Increased hydrostatic pressure in portal circulation increases

fluid shifts into abdomen

C. Increased circulating aldosterone levels that increase sodium and water

retention

The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies)

Murmur

A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4cm by 7cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?

A) Transparent dressing

B) Dry sterile dressing with antibiotic ointment

C) Wet to dry dressing

D) Occlusive moist dressing

D) Occlusive moist dressing

A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse to select from the toy room for this child?

A) Cartoon stickers

B) Large wooden puzzle

C) Blunt scissors and paper

D) Beach ball

B) Large wooden puzzle

A nurse is to present information about Chinese folk medicine to a group of student

nurses. Based on this cultural belief, the nurse would explain that illness is attributed to the

A) Yang, the positive force that represents light, warmth, and fullness

B) Yin, the negative force that represents darkness, cold, and emptiness

C) Use of improper hot foods, herbs and plants

D) A failure to keep life in balance with nature and others

B) Yin, the negative force that represents darkness, cold, and emptiness

A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse "What is our major concern now, and what will we have to deal with in the future?" Which of the following is the best response?

A) "There is a probability of life-long complications."

B) "Cystic fibrosis results in nutritional concerns that can be dealt with."

C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."

D) "You will work with a team of experts and also have access to a support group that the family can attend."

C) "Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis."

Which type of accidental poisoning would the nurse expect to occur in children under

age 6?

A) Oral ingestion

B) Topical contact

C) Inhalation

D) Eye splashes

A) Oral ingestion

A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client?

A) Reading

B) Checkers

C) Cards

D) Ping-pong

D) Ping-pong

The nurse is caring for a client who has developed cardiac tamponade. Which finding

would the nurse anticipate?

A) Widening pulse pressure

B) Pleural friction rub

C) Distended neck veins

D) Bradycardia

C) Distended neck veins

Which nursing action is a priority as the plan of care is developed for a 7 year-old

child hospitalized for acute glomerulonephritis?

A) Assess for generalized edema

B) Monitor for increased urinary output

C) Encourage rest during hyperactive periods

D) Note patterns of increased blood pressure

D) Note patterns of increased blood pressure

The nurse is caring for a child receiving chest physiotherapy (CPT). Which of the

following actions by the nurse would be appropriate?

A) Schedule the therapy thirty minutes after meals

B) Teach the child not to cough during the treatment

C) Confine the percussion to the rib cage area

D) Place the child in a prone position for the therapy

C) Confine the percussion to the rib cage area

Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?

A) Orthostatic hypotension is a common side effect

B) Most antipsychotic drugs cause elevated blood pressure

C) This provides information on the amount of sodium allowed in the diet

D) It will indicate the need to institute anti parkinsonian drugs

A) Orthostatic hypotension is a common side effect

The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs?

A) Three apricots

B) Medium banana

C) Naval orange

D) Baked potato

D) Baked potato

An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

A) Add a thickening agent to the fluids

B) Check the client's gag reflex

C) Feed the client only solid foods

D) Increase the rate of intravenous fluids

B) Check the client's gag reflex

The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?

A) Place client in the wheelchair for four hours each day

B) Pad the bony prominence

C) Reposition every two hours

D) Massage reddened bony prominence

C) Reposition every two hours

A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers?

A) A 79 year-old malnourished client on bed rest

B) An obese client who uses a wheelchair

C) A client who had 3 incontinent diarrhea stools

D) An 80 year-old ambulatory diabetic client

C) A client who had 3 incontinent diarrhea stools

Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority?

A) Obtain a complete blood count

B) Obtain a health and dietary history

C) Refer to a provider for a physical examination

D) Measure height and weight

B) Obtain a health and dietary history

After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is

A) Abdominal x-ray

B) Auscultation

C) Flushing tube with saline

D) Aspiration for gastric contents

A) Abdominal x-ray

A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client?A) Allow the client to melt ice chips in the mouth

B) Provide mints to freshen the breath

C) Perform frequent oral care with a tooth sponge

D) Swab the mouth with glycerin swabs

C) Perform frequent oral care with a tooth sponge

The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

A) Exercise doing weight bearing activities

B) Exercise to reduce weight

C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones

A) Exercise doing weight bearing activities

The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?

A) Cheese sandwich with a glass of 2% milk

B) Sliced turkey sandwich and canned pineapple

C) Cheeseburger and baked potato

D) Mushroom pizza and ice cream

B) Sliced turkey sandwich and canned pineapple

Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol?

A) All 4 side rails up, wheels locked, bed closest to door

B) Lower side rails up, bed facing doorway

C) Knees bent, head slightly elevated, bed in lowest position

D) Bed in lowest position, wheels locked, place bed against wall

D) Bed in lowest position, wheels locked, place bed against wall

The nurse is talking to parents about nutrition in school aged children. Which of the following is the most common nutritional disorder in this age group?

A) Bulimia

B) Anorexia

C) Obesity

D) Malnutrition

C) Obesity

At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for me." The nurse should

A) Invite the client to join the exercise group

B) Tell the client you will call someone to come for her

C) Give the client simple information about what she will be doing

D) Firmly direct the client to her assigned group activity

C) Give the client simple information about what she will be doing

A victim of domestic violence states to the nurse, "If only I could change and be how my companion wants me to be, I know things would be different." Which would be the best response by the nurse?

A) "The violence is temporarily caused by unusual circumstances, don't stop hoping for a change.

"B) "Perhaps, if you understood the need to abuse, you could stop the violence.

"C) "No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?"

D) "Batterers lose self-control because of their own internal reasons, not because of what their

partner did or did not do."

D) "Batterers lose self-control because of their own internal reasons, not because of what their

partner did or did not do."

A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation?

A) Degeneration of the alveoli

B) Chronic broncho constriction of the large airways

C) Lung remodeling and permanent changes in lung function

D) Frequent pneumonia

C) Lung remodeling and permanent changes in lung function

A mother wants to switch her 9 month-old infant from an iron fortified formula to whole milk because of the expense. Upon further assessment, the nurse finds that the baby eats table foods well, but drinks less milk than before. What is the best advice by the nurse?

A) Change the baby to whole milk

B) Add chocolate syrup to the bottle

C) Continue with the present formula

D) Offer fruit juice frequently

C) Continue with the present formula

Privacy and confidentiality of all client information is legally protected. In which of

these situations would the nurse make an exception to this practice?

A) When a family member offers information about their loved one

B) When the client threatens self-harm and harm to others

C) When the health care provider decides the family has a right to know the client's diagnosis

D) When a visitor insists that the visitor has been given permission by the client

B) When the client threatens self-harm and harm to others

The nurse is caring for a client who is in the late stage of multiple myeloma. Which of

the following should be included in the plan of care?

A) Monitor for hyperkalemia

B) Place in protective isolation

C) Precautions with position changes

D) Administer diuretics as ordered

C) Precautions with position changes

The nurse is making a home visit to a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which diagnosis would be most appropriate for this client based on this assessment?

A) Activity intolerance caused by fatigue related to chronic tissue hypoxia

B) Impaired mobility related to chronic obstructive pulmonary disease

C) Self-care deficit caused by fatigue related to dyspnea

D) Ineffective airway clearance related to increased bronchial secretions

A) Activity intolerance caused by fatigue related to chronic tissue hypoxia

The nurse admits a client newly diagnosed with hypertension. What is the best

method for assessing the blood pressure?

A) Standing and sitting

B) In both arms

C) After exercising

D) Supine position

B) In both arms

The nurse is caring for residents in a long term care setting for the elderly. Which of the following activities will be most effective in meeting the growth and development needs for persons in this age group?

A) Aerobic exercise classes

B) Transportation for shopping trips

C) Reminiscence groups

D) Regularly scheduled social activities

C) Reminiscence groups

Post-procedure nursing interventions for electroconvulsive therapy include

A) Applying hard restraints if seizure occurs

B) Expecting client to sleep for 4 to 6 hours

C) Remaining with client until oriented

D) Expecting long-term memory loss

C) Remaining with client until oriented

The nurse assesses delayed gross motor development in a 3 year-old child. The

inability of the child to do which action confirms this finding?

A) Stand on 1 foot

B) Catch a ball

C) Skip on alternate feet

D) Ride a bicycle

A) Stand on 1 foot

The mother of a 15 month-old child asks the nurse to explain her child's lab results

and how they show her child has iron deficiency anemia. The nurse's best response is

A) "Although the results are here, your doctor will explain them later.

"B) "Your child has less red blood cells that carry oxygen.

"C) "The blood cells that carry nutrients to the cells are too large."

D) "There are not enough blood cells in your child's circulation."

B) "Your child has less red blood cells that carry oxygen."

In a child with suspected coarctation of the aorta, the nurse would expect to find

A) Strong pedal pulses

B) Diminishing carotid pulses

C) Normal femoral pulses

D) Bounding pulses in the arms

D) Bounding pulses in the arms

At the day treatment center a client diagnosed with Schizophrenia - Paranoid Type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates

A) Feelings of increasing anxiety related to paranoia

B) Social isolation related to altered thought processes

C) Sensory perceptual alteration related to withdrawal from environment

D) Impaired verbal communication related to impaired judgment

B) Social isolation related to altered thought processes

A 65-year-old Hispanic-Latino client with prostate cancer rates his pain as a 6 on a 0- to-10 scale. The client refuses all pain medication other than Motrin, which does not relieve his pain. The next action for the nurse to take is to

A) Ask the client about the refusal of certain pain medications

B) Talk with the client's family about the situation

C) Report the situation to the health care provider

D) Document the situation in the notes

A) Ask the client about the refusal of certain pain medications

What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

A) Presence of blood in stools

B) Oozing liquid stool

C) Continuous rumbling flatulence

D) Absence of bowel movements

B) Oozing liquid stool

A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

A) Have the client identify coping methods

B) Get the description of the location and intensity of the pain

C) Accept the client's report of pain

D) Determine the client's status of pain

C) Accept the client's report of pain

An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be

A) Assess the severity and location of the pain

B) Obtain an order for an analgesic

C) Reassure him that this is not unusual for his age

D) Encourage him to increase his activity

A) Assess the severity and location of the pain

A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that:

A) Visitors must wear a mask and a gown

B) There are no special requirements for visitors of clients on contact precautions

C) Visitors should wash their hands before and after touching the client

D) Visitors

C) Visitors should wash their hands before and after touching the client

A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?

A) Institute seizure precautions

B) Monitor neurologic status every hour

C) Place in respiratory/secretion precautions

D) Cefotaxime IV 50 mg/kg/day divided q6h

C) Place in respiratory/secretion precautions

Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

A) Sensory perceptual alterations related to decreased vision

B) Alteration in mobility related to fatigue

C) Impaired gas exchange related to retained secretions

D) Altered patterns of urinary elimination related to nocturia

D) Altered patterns of urinary elimination related to nocturia