HESI RN 2025 EXIT EXAM MOST TESTED EXAM QUESTIONS AND ANSWERS GRADED A+ ASSURED SUCCESS

When preparing to administer a prescribed medication to a homeless client at a community psychiatric clinic. The client tells the nurse that the usual dosage taken is different from the dose the nurse is giving. Which action should the nurse take?

A) Inform the client that he may refuse the medication and document whether or not the client takes it.

B) Withhold the medication until the dosage can be confirmed.

C) Explain to the client that the dosage has been changed.

D) Tell the client to take the medication then verify the dosage at the next healthcare team meeting.

B) Withhold the medication until the dosage can be confirmed.

The charge nurse is making assignments for one practical nurse and three registered nurses who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

A) Subdural hematoma whose blood pressure changed from 150/80 to 170/60.

B) Viral meningitis whose temperature change from 101 S to 102F.

C) Diabetic keto acidosis who is Glasgow coma scale score changed from 10 to 7.

D) Myxedema, whose blood pressure change from 80/50 to 70/40.

B) Viral meningitis whose temperature change from 101 S to 102F.

The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

A) Maintain strict intake and output.

B) Keep head of bed raised 45°.

C) Excess warmth of extremities.

D) Monitor blood glucose level.

A) Maintain strict intake and output.

And adolescent client is admitted to the hospital because of writing a suicide note to a teacher at school. On the second day of hospitalization, the nurse asked the client to meet with the treatment team. After the team meeting, the client leaves in tears and goes to their room. Which nursing intervention is best?

A) Let the client rest quietly in their room for a while.

B) Explore the clients goals and desire for treatment.

C) Ask the treatment team about the clients behavior.

D) Go to the clients room and ask what happened.

D) Go to the clients room and ask what happened.

The healthcare provider prescribes dalteparin 200 units per kilogram subcutaneous once a day for a client who weighs 154 pounds. The medication is available and 25,000 units per milliliter vial. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest 10th.)

0.6

NGN: The client is a 49-year-old male who reports flu like symptoms including fever and chest congestion for four days. He came to the emergency department last night when he was having more difficulty breathing he has a history of 1/2 pack a day cigarette smoking for 20 years. He has no significant medical or surgical history.

Which two orders should the nurse complete first?

A) Sputum culture.

B) Start oxygen 3 L per minute via nasal cannula.

C) Place the client on a cardio respiratory monitor.

D) Chest x-ray.

E) Acetominophen 350 mg PO every six hours for temperature control.

F) Run 0.9% sodium chloride IV infusion at 150 mL per hour.

G) Start peripheral IV.

H) NPO.

B) Start oxygen 3 L per minute via nasal cannula.

C) Place the client on a cardio respiratory monitor.

NGN: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start a peripheral IV infusion, start oxygen 3 L per minute via nasal cannula, begin 0.9% sodium chloride IV infusion at 150 mL per hour, acetaminophen 350 mg PO every six hours for temperature.

To start the client on oxygen as ordered which items should the nurse collects from the supply room? SATA

A) humidifier bottle.

B)Suction canister.

C)Sterile water.

D) Nasal cannula.

E) Flow meter.

F) Lambs wool.

G) Tape.

D) Nasal cannula.

E) Flow meter.

NGN: states, I am feeling extremely anxious right now. The client has decreased breath sounds in the left lower low. His mucus membranes are dry. He has a productive cough with thick, yellow secretions. His capillary refill is four seconds. Vital signs, temperature 100.2. Heart rate 101 bpm, respiratory rate 28 breaths per minute, blood pressure 145/89, oxygen saturation 90% on room air.

(for each body system click to specify the assessment findings that indicates hypoxia)

Cardiovascular: heart rate 100 bpm, capillary refill for seconds, blood pressure 145/89.

Neurological: anxious, awake and alert, restless.

Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm, productive cough.

Cardiovascular: capillary refill for seconds, blood pressure 145/89.

Neurological: anxious, restless.

Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm.

NGN: The client is a 49-year-old male who reports flu like symptoms including fever and chest congestion for four days. He came to the emergency department last night when he was having more difficulty breathing he has a history of 1/2 pack a day cigarette smoking for 20 years. He has no significant medical or surgical history.

The nurse should place the client in a _______________ position to promote _____________.

Semi-Fowler , lung expansion.

NGN: Orders: 0330: place the client on a cardio respiratory monitor, NPO, sputum culture, start a PIV, start oxygen 3L via nasal cannula, normal saline 150 ML per hour, acetaminophen 350mg PO every six hours for temp greater than 101F, chest x-ray.

0500: Oxygen 8Lvia simple facemask, titrate to keep oxygen saturation greater than 94%.

(mark whether the statements by the new grad nurse indicate understanding or no understanding of the use of facemask in the care of this client)

-I should clean the facemask once per shift.

-The client should take a 1 to 2 minute break from the facemask each hour.

-I should put gauze under the elastic straps over the ears.

-I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation greater than 94%.

-The mask should cover only the mouth and leave the nose open for expiration.

-I should place the mask first over the nose and then cover the mouth.

-I should clean the facemask once per shift. (UNDERSTANDING)

-The client should take a 1 to 2 minute break from the facemask each hour. (NOT UNDERSTANDING)

-I should put gauze under the elastic straps over the ears. (NOT UNDERSTANDING ????)

-I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation greater than 94%. (UNDERSTANDING)

-The mask should cover only the mouth and leave the nose open for expiration. (NOT UNDERSTANDING)

-I should place the mask first over the nose and then cover the mouth. (UNDERSTANDING)

NGN: Nurses Notes: 0400, the client is awake and alert but restless. He states I am feeling extremely anxious right now. The client has decreased breath sounds in the left lower lobe. His mucus membranes are dry. He has a productive cough with thick, yellow secretions. His capillary refill is four seconds. Heart rate 101 BPM, oxygen saturation 90%. Blood pressure 145/89, temperature 100.2 F, respiratory rate 28 BPM.

0500: Placedthe client in semi-Fowlers position. No improvement in oxygen saturation on 3L nasal cannula...

(Which are the three most important goals?)

A) The client will remain free of skin breakdown.

B) The client will have quit smoking.

C) The client will be afebrile for 24 hours.

D) The client will maintain oxygen saturation of 96% without supplemental oxygen.

E) The client will report pain less than 3/10.

B) The client will have quit smoking.

C) The client will be afebrile for 24 hours.

E) The client will report pain less than 3/10.

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high-protein diet is encouraged to promote wound healing. Which lunch toys by the client indicates that the teaching was effective?

A) A peanut butter sandwich with soda and cookies.

B) Vegetable soup, crackers, and milk.

C) A tuna fish sandwich with chips and ice cream.

D) A salad with three kinds of lettuce and fruit.

C) A tuna fish sandwich with chips and ice cream.

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected MRSA. Which nursing intervention should the nurse include in the plan of care? SATA.

A) Institute contact precautions for staff and visitors.

B) Use standard precautions and wear a mask.

C) Send wound drainage for culture and sensitivity.

D) Monitor the clients white blood cell count.

E) Explain the purpose of a low bacteria diet.

A) Institute contact precautions for staff and visitors.

C) Send wound drainage for culture and sensitivity.

D) Monitor the clients white blood cell count.

An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider?

A) Weight loss of 10 pounds in the past month.

B) Six hours of sleep in the past three days.

C) Blood alcohol level of 0.09%.

D) Serum lithium level of 1.6.

D) Serum lithium level of 1.6.

When conducting diet teaching for a client who is on a post operative full liquid diet, which foods should the nurse encouraged the client to eat? SATA.

A) Clear beef broth.

B) Vanilla frozen yogurt.

C) Vegetable juice.

D) Creamy peanut butter.

E) Canned fruit cocktail.

A) Clear beef broth.

B) Vanilla frozen yogurt.

C) Vegetable juice.

An infant born with esophageal atresia and tracheoesophageal fistula receives a prescription for internal feedings after corrective surgery. To promote normal growth and development of the infant, which action should the nurse include in the plan of care?

A) Administer feedings via gastrostomy tube only until oral feeding is fully established

B) Place the infant in a side-lying position during and after feedings

C) Minimize oral stimulation to prevent aspiration during recovery

D) Offer a pacifier for non-nutritive sucking

D) Offer a pacifier for non-nutritive sucking

The nurse is preparing a four month old client with a serum bilirubin level of 19 for discharge from the hospital. When teaching the parents about home photo therapy, which instruction should the nurse include in the discharge teaching plan?

A) Cover with a receiving blanket.

B) Perform diaper changes under the light.

C) Feed the infant every four hours.

D) Reposition the infant every two hours.

D) Reposition the infant every two hours.

The nurse initiate the procedure to remove a clients peripherally inserted central catheter when a code blue is called for another client in the unit who collapse in the hallway while ambulating with the unlicensed assistive personnel. Which action should the nurse take?

A) Close the room door.

B) Finish the procedure.

C) Respond to the code.

D) Call for an assistant.

B) Finish the procedure.

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?

A) Maintain a quiet, non-stimulating environment.

B) Confront the clients denial of substance abuse.

C) Force oral fluids and provide frequent small meals.

D) Encourage attendance and group participation.

A) Maintain a quiet, non-stimulating environment.

A client arrives at the emergency department describing chest pain that began three hours earlier which has not subsided. To assess the quality of the clients chest pain. Which approach for the nurse use?

A) Provide a numeric pain scale.

B) Ask the client to describe the pain.

C) Identify effective pain relief measures.

D) Observe body language and movement.

B) Ask the client to describe the pain.

An adolescent who was diagnosed with type one diabetes Molite us at the age of nine, is admitted to the hospital in diabetic keto acidosis. Which occurrence is the most likely cause of the keto acidosis?

A) Ate an extra peanut butter sandwich before gym class.

B) Incorrectly administered too much insulin.

C) Had a cold and ear infection for the past two days.

D) Skipped eating lunch while at school.

C) Had a cold and ear infection for the past two days.

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes?

A) Within the first trimester of pregnancy.

B) When the client has ankle edema.

C) During admission to labor and delivery.

D) If the client has an elevated blood pressure.

D) If the client has an elevated blood pressure.

NGN: The client has returned to work at in accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informed that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all". In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.

(highlight areas in the above paragraph that the nurse should...)

-she only gets 2 to 3 hours of sleep due to nightmares about the crash.

-She feels that she is "jumpy" after the accident, especially when she is in the car.

- "I feel so sad that I can't seem to feel anything at all"

The client is a 26 year old female who was in a car accident six months ago that killed her mother, husband, and two year old son. She and her father were the only survivors of the crash. She is seeking care for depression.

The client is exhibiting symptoms of ________________________ related to ______________ and ___________________.

Post traumatic stress disorder , experiencing a life-threatening event , losing a loved one.

NGN: Orders, diagnosis, depression and posttraumatic stress disorder. Diphenhydramine 12.5 mg PO every night at sleep. BuspironeHydrochloride 7.5 mg PO twice a day.

(how can the nurse build a therapeutic relationship with the client? Select all that apply)

A) The nurse can show no emotion when talking to the client.

B) The nurse can be open honest and sincere.

C) The nurse can talk as much as needed to get the client talking.

D) The nurse can focus energy on the client.

E) The nurse can communicate acceptance of the client as she is

F) The nurse can establish a meaningful connection.

B) the nurse can be open, honest and sincere.

E) The nurse can communicate acceptance of the client as she is

F) The nurse can establish a meaningful connection.

NGN: The client has returned to work at in accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informed that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all". In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use. The client states, "I don't want to kill myself, but sometimes I wish I had died in the crash."

The statement by the client presents _______________ and should be followed up with _____________.

Suicidal ideation, assessment of respecters for suicide.

The client is a 26 year old female who was in a car accident six months ago that killed her mother, husband, and two year old son. She and her father were the only survivors of the crash. She is seeking care for depression.

(what would be some affective strategies that the nurse could use to decrease the clients risk of suicide in the future? SATA.)

A) Have the client remove any sharp objects from the home.

B) Have the client sign a no suicide contract.

C) Help the client unless the help of friends and family.

D) Make the client feel too guilty to commit suicide.

E) Place the client in a locked unit.

F) Refer the client for cognitive behavioral therapy.

B) Have the client sign a no suicide contract.

C) Help the client unless the help of friends and family.

F) Refer the client for cognitive behavioral therapy.

The client is a 26 year old female who was in a car accident six months ago that killed her mother, husband, and two year old son. She and her father were the only survivors of the crash. She is seeking care for depression.

(which findings are effective or ineffective)

-The client states she feels less jumpy and more relaxed.

-The client states she feels numb when thinking about the crash.

-The client talks to her father and her best friend when she starts to feel sad.

-The client reports sleeping 6 to 7 hours per night.

-The client states that she avoids driving altogether and takes the bus.

-The client states she feels less jumpy and more relaxed. (EFFECTIVE)

-The client states she feels numb when thinking about the crash. (INEFFECTIVE)

-The client talks to her father and her best friend when she starts to feel sad. (EFFECTIVE)

-The client reports sleeping 6 to 7 hours per night. (EFFECTIVE)

-The client states that she avoids driving altogether and takes the bus. (INEFFECTIVE)

The healthcare provider prescribes acarbose, an alpha-glucosidase inhibitor, for a client with type two diabetes. Which information provides the best indicator of the drugs effectiveness?

A) Body mass index between 20 and 24.

B) Blood pressure readings less than 120/80.

C) Self-reported glucose levels 120 to 150.

D) Hemoglobin A1c readings less than 7%.

D) Hemoglobin A1c readings less than 7%.

After receiving report on an inpatient acute care unit which client should the nurse assess first?

A) The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds.

B) The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid.

C) The client with an obstruction of the large intestine who is experiencing abdominal distention.

D) The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity.

D) The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity.

Client presents at the emergency department reporting a raspy voice, cold intolerance, and fatigue. Laboratory tests indicate an elevated thyroid stimulating hormone and a low T3 and T4 levels. After the client is admitted to the telemetary unit, which intervention is most appropriate for the nurse to implement?

A) administer prescribed dose of level thyroxine.

B) Note clients most recent hemoglobin level.

C) Offer additional blankets and a warm drink.

D) Assess for the presence of nonpitting edema.

A) administer prescribed dose of level thyroxine.

While caring for a client post operative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take?

A) Determine if the drainage has an unpleasant odor.

B) Cleanse the wound with a sterile saline solution.

C) Monitor the clients white blood cell count.

D) Request a culture and sensitivity of the wound.

D) Request a culture and sensitivity of the wound.

The school nurse is screening students for scoliosis and notes that one student has lordosis. Which finding should the nurse document in the student screening record?

A) Lateral curvature that creates a symmetry of the shoulders.

B) Posterior curvature that is convex in the thoracic area.

C) Excessive concave curvature of the lumbar spine.

D) Rounded spine from head to hips without concave curbs.

C) Excessive concave curvature of the lumbar spine.

The nurse is assigned to care for for surgical clients. After receiving report, which client should the nurse see first?

A) An older client who is receiving packed red blood cells on the third day post operative for colon resection.

B) An older client with continuous bladder irrigation who is two days post operative for bladder surgery.

C) An adult who is in bucks traction, and scheduled for hip arthroplasty within the just 12 hours.

D) An adult one day post operative laparoscopic cholecystectomy requesting pain medication.

A) An older client who is receiving packed red blood cells on the third day post operative for colon resection.

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situation and perceived stress. In addition to information about prescribe medication and administration, which instruction should the nurse include in the teaching?

A) Think about reasons the episodes occur.

B) Center attention on positive upbeat music.

C) Practice using muscle relaxation techniques.

D) Find outlets for more social interaction.

C) Practice using muscle relaxation techniques.

The nurse is preparing a client who had a below the knee amputation for discharge to home. Which recommendations should the nurse provide this client? SATA.

A) Use a residual limb shrinker.

B) Inspect skin for redness.

C) Apply alcohol to the residual limb after bathing.

D) Wash the residual limb with soap and water.

E) Avoid range of motion exercises.

A) Use a residual limb shrinker.

B) Inspect skin for redness.

D) Wash the residual limb with soap and water.

The nurse is assessing the feet of a client with type one diabetes mellitis. Which finding requires immediate intervention by the nurse?

A) Hard, painless nodule over metatarsophalangeal joint of first toe.

B) Painful corns and calluses over hammer toes on both feet.

C) Erythema and edema at the base of the left great toe.

D) Decreased response to pain discrimination on dorsal surface of foot.

D) Decreased response to pain discrimination on dorsal surface of foot.

The school nurse is called to the soccer field because a child has epistaxis. In which position should the nurse place the child?

A) Side-lying with the head slightly elevated.

B) Sitting up and leaning forward.

C) Standing with the head leaning backwards.

D) Supine with the legs raised.

B) Sitting up and leaning forward.

The nurse is auscultating a clients lung sounds. Which description should the nurse use to document this sound? Please listen to the audio file to select the option that applies.

A) High pitch squeeze.

B) Rhonchi.

C) High-pitched or fine crackles.

D) Stridor.

C) High-pitched or fine crackles.

NGN: Flow Sheet, vital signs, heart rate 104 bpm, respiratory rate 31 bpm.

The client is experiencing __________________ and ____________________.

Tachypnea , tachycardia

NGN: Orders, 1300 admit to the surgical unit, vital signs every four hours, advanced diet as tolerated, administer lactated ringers IV at 85 mL per hour, ibuprofen 800 mg PO every eight hours PRN for pain.

(the nurse would anticipate which of the following could be affecting the clients current condition? SATA.

A) stress.

B) Medication.

C) Anemia.

D) Fever.

E) Hypothermia.

F) Hypertension.

G) Pain.

A) stress.

B) Medication.

G) Pain.

NGN: the client is a 34-year-old female who had a surgical procedure to remove a benign abdominal tumor.

(Select which is understanding or not understanding)

-The tubing should be tucked under the chin and secured with the sliding adjustment piece.

-Humidification of oxygen is not needed for administration under 4 L per minute.

-The nasal cannula can deliver up to 10 L per minute of oxygen.

-A nasal cannula delivers 100% oxygen to the client.

-The tubing should be tucked under the chin and secured with the sliding adjustment piece. (UNDERSTANDING)

-Humidification of oxygen is not needed for administration under 4 L per minute. (UNDERSTANDING)

-The nasal cannula can deliver up to 10 L per minute of oxygen. (NOT UNDERSTANDING)

-A nasal cannula delivers 100% oxygen to the client. (NOT UNDERSTANDING)

NGN: Orders, 1300 admit to the surgical unit, vital signs every four hours, advanced diet as tolerated, administer lactated ringers IV at 85 mL per hour, ibuprofen 800 mg PO every eight hours PRN for pain.

1310: supplemental oxygen at 2

(what diagnostic test would be appropriate for this client? SATA)

A) Doppler.

B) Blood gases.

C) Blood culture.

D) Complete blood count.

E) Urinalysis.

F) Chest radiograph.

G) Echocardiogram.

B) Blood gases.

D) Complete blood count.

F) Chest radiograph.

NGN: Nurses Notes, saturation is low. Noted cyanosis in the clients lips. Healthcare provider made aware.

1310: pain rating for on a pain scale of 0 to 10. Temperature elevation noted. The client is anxious and using accessory muscles to breathe. Alerted the surgeon about the client status. New orders noted.

(what does the nurse need to document at 1330? SATA)

A) urine output.

B) Respiratory rate.

C) Blood pressure.

D) Pain.

E) Temperature.

F) Flow rate of oxygen.

G) Oxygen saturation.

B) Respiratory rate.

C) Blood pressure.

D) Pain.

E) Temperature.

G) Oxygen saturation.

NGN: Match the activity with the most appropriate person to do the activity.

-Provide mouth care.

-Document changes in respiratory status.

-Set up the oxygen administration system.

-Change the gauze under the nasal cannula.

-Provide mouth care. (UAP)

-Document changes in respiratory status. (RN/RT)

-Set up the oxygen administration system. (RN/RT)

-Change the gauze under the nasal cannula. (UAP)

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

A) IV administration of benztropine.

B) IV administration of isotonic crystalloid fluid.

C) PO administration of lorazepam.

D) PO administration of divalproex.

A) IV administration of benztropine.

A client with heart failure become short of breath, anxious, and has audible reasoning with pink frothy sputum. The nurse sits the client upright and provides oxygen per nasal cannula. The nurse receives a prescription to administer a one time dose of morphine sulfate IV. Which action should the nurse take?

A) Administer the dose of morphine sulfate as prescribed.

B) Consult with the charge nurse regarding the morphine prescription.

C) Review the need for the prescription with the healthcare provider.

D) Withhold the morphine until the clients dyspnea resolves.

A) Administer the dose of morphine sulfate as prescribed.

A client with acute asthma exacerbation is manifesting inspiratory and expiratory wheezes and a decreased forced expiratory volume. Which prescribed drug class should the nurse administer first to the client?

A) Inhaled short acting beta two agonists.

B) Inhaled corticosteroids.

C) Anti-cholinergics.

D) Leukotriene modifiers.

B) Inhaled corticosteroids.

The nurse enters a clients room to administer oral medication's and find an unlicensed assistive personnel 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. Which is the priority nursing action?

A) Determine why the UAP did not notify the nurse of the change in the clients condition.

B) Advised the UAP to stop providing care so the nurse can assess the clients condition.

C) Explain to the UAP that changes in a clients condition should be reported immediately.

D) Ask for UAP to position the client so the oral medication's can be administered.

B) Advised the UAP to stop providing care so the nurse can assess the clients condition.

The client who was admitted yesterday with severe dehydration is reporting pain where a 24 gauge IV catheter with 0.9% sodium chloride is infusing at a rate of 150 mL per hour. Which intervention should the nurse implement first?

A) Discontinue the 24 gauge IV.

B) Establish a second IV site.

C) Stop the 0.9% sodium chloride infusion.

D) Assess the IV for blood return.

C) Stop the 0.9% sodium chloride infusion.

Client should the nurse assess frequently because of the risk for overflow incontinence?

A) a client with hematuria and decreasing hemoglobin and hematocrit levels.

B) A client who has been fast, with increased serum creatinine levels.

C) A client who is confused and frequently forgets to go to the bathroom.

D) A client who has a history of frequent urinary tract infections.

C) A client who is confused and frequently forgets to go to the bathroom.

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? SATA.

A) Location of the initial IV site.

B) Swollen lymph nodes in the groin.

C) Red blood cell count.

D) White blood cell count.

E) Core body temperature.

B) Swollen lymph nodes in the groin.

D) White blood cell count.

E) Core body temperature.

A client develops your to Caria on the trunk and neck shortly after a secondary infusion of pepper Sillen is initiated. In which order should the nurse implement these interventions?

Document reaction of the drug.

Contact the healthcare provider.

Assess vital signs.

Stop the infusion.

Initiate an adverse event report.

Stop the infusion.

Assess vital signs.

Contact the healthcare provider.

Initiate an adverse event report.

Document reaction to drug.

What nursing intervention is particularly indicated for the second stage of labor?

A) Assessing the fetal heart rate and patterns for signs of fetal distress.

B) Monitoring effects of oxytocin administration to help achieve cervical dilation.

C) Providing pain medication to increase the clients tolerance of labor pains.

D) Assisting the client to push effectively so that expulsion of the fetus can be achieved.

D) Assisting the client to push effectively so that expulsion of the fetus can be achieved.

A client receives a prescription for Aceta medicine 1000 mg PO every eight hours PRN for pain. The bottle is labeled acetaminophen for oral suspension, US P 500 mg per 15 mL. How many tablespoons should the nurse administer with each dose? (Enter numerical value only.)

2

15 mL per tablespoon

The nurse is administering multiple prescribe vaccines to a toddler. Which strategy should the nurse prioritized to reduce the duration of pain?

A) Supine positioning.

B) Verbal reassurance.

C) Simultaneous injections.

D) Physical soothing.

C) Simultaneous injections.

NGN: Dean 30, admit to the medical floor, vital signs every four hours, regular diet, out of bed with assist.

Complete diagram with one condition, two actions, and two parameters.

Actions: the client for a nutrition history, encourage the client to drink

Condition: Malnutrition

Actions: ?????

????????

When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. Which action should the nurse implement first?

A) Check for a distended bladder.

B) Review the hemoglobin to determine hemorrhage.

C) Increase IV infusion rate.

D) Massage the uterus to decrease atony.

A) Check for a distended bladder.

A client who is receiving zidovudine reports the appearance of pinpoint, red, brown spots on the skin. Which result should the nurse report to the healthcare provider?

A) Skin biopsy.

B) Complete blood count.

C) Allergy test.

D) Electromyography.

B) Complete blood count.

Petechiae can occur due to low platelet counts. Zidovudine is used for HIV and can cause hematological toxicity, anemia neutropenia.

A child newly diagnosed with sickle cell anemia is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?

A) Instructions about how much fluid the child to drink daily.

B) Referral for social services for the child and family.

C) Signs of addiction to opioid pain medications.

D) Information about nonpharmaceutical pain relief measures.

A) Instructions about how much fluid the child to drink daily.

During discharge teaching, and overweight client with heart failure is asked to make a grocery list for the nurse to review. Which food choices include it on the clients list should the nurse encouraged? SATA.

A) Cheddar cheese cubes.

B) Canned fruit in heavy syrup.

C) Lightly salted potato chips.

D) Plain, air-popped popcorn.

E) Natural whole almonds.

D) Plain, air-popped popcorn.

E) Natural whole almonds.

A client is receiving IV fluids by gravity infusion and exhibit signs of fluid volume overload. When assessing the clients IV delivery system, where should the nurse assess first?

A

I can't see all the pics. Use the clamp on the IV tubing.

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? SATA.

A) Widen stance while working near the sink.

B) Leans forward to pull a pan from a high shelf.

C) Tenths from the waist to pick trash off the floor.

D) Brings a heavy can close to body before lifting.

E) Lots knees while preparing food on the counter.

A) Widen stance while working near the sink.

D) Brings a heavy can close to body before lifting.

A client is receiving methylamine 800 mg PO three times a day. Which assessment should the nurse perform to assess the effectiveness of the medication?

A) Bowel patterns.

B) Pupillary response.

C) Peripheral pulses.

D) Oxygen saturation.

A) Bowel patterns.

Ulcerative colitis medication that helps reduce inflammation in the G.I..

Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspect the client may have had a pulmonary embolus. Which action should the nurse take first?

A) Provide supplemental oxygen.

B) Prepare a continuous heparin infusion per protocol.

C) Bring the emergency craft cart to the bedside.

D) Notify the healthcare provider.

A) Provide supplemental oxygen.

The nurse identifies an electrolyte imbalance, elevated blood pressure, and exhibited changes in mental status for a client with chronic kidney disease. Which is the most important action for the nurse to take?

A) Monitor daily sodium intake.

B) Auscultate for a regular heart rate.

C) Document abdominal girth.

D) Measure ankle circumference.

B) Auscultate for a regular heart rate.

The older adult client who has difficulty hearing is being discharged from the day surgeries following a cataract extraction and lens in plantation. Which intervention is most important for the nurse to implement to help ensure the client compliant with self-care?

A) Ensure that someone will stay with the client for 24 hours.

B) Have a client vocalize the instructions provided.

C) Speak clearly and face the client for lip reading.

D) Provide written instructions for eyedrop administration.

B) Have a client vocalize the instructions provided.

NO QUESTION 68

Well making rounds, the charge nurse notices that a young adult client with asthma who has admitted yesterday is sitting on the side of the bed and leaning over the side table. The client is currently receiving oxygen at 2 L per minute via nasal cannula. The client is wheezing and is using per slip breathing. Which intervention should the nurse implement?

A) Increase oxygen to 6 L per minute.

B) Call for an Ambu resuscitation bag.

C) This is the client to lie back in bed.

D) Administer a nebulizer treatment.

D) Administer a nebulizer treatment.

An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which non-pharmacological intervention should the nurse implement?

A) Clarify reality with the client about delusional thoughts.

B) Use distraction and therapeutic communication skills.

C) Reduce the clients interaction with others during the day.

D) Awakening the client for reality checks every four hours at night.

B) Use distraction and therapeutic communication skills.

Four hours after surgery, a client reports nausea and begins to vomit. The nurse knows that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?

A) Reposition the transdermal patch to the clients trunk.

B) Remove the transdermal patch until the vomiting subsides.

C) Notify the clients healthcare provider of the vomiting.

D) Explain that this is a side effect of the medication in the patch.

C) Notify the clients healthcare provider of the vomiting.

This medication is used for nausea and the provider should be made aware if the medication is not effective.

The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. Which action should the nurse take? SATA.

A) Instruct the adult child to check the clients temperature.

B) Encourage increased intake of high protein foods.

C) Determine if the client has recently experienced a fall.

D) Reviewed the clients current food and medication allergies.

E) Ask if the client is experiencing any pain with urination.

A) Instruct the adult child to check the clients temperature.

C) Determine if the client has recently experienced a fall.

E) Ask if the client is experiencing any pain with urination.

The healthcare provider prescribes 30 survive for a four-year-old child who has a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective?

A) Urine specific gravity change from 1.0212 1.031.

B) Urinary output decreases of 5 mL per hour.

C) Daily weight decrease of 2 pounds.

D) Blood urea nitrogen increase from 8 to 12.

C) Daily weight decrease of 2 pounds.

Lasix is a diarrhetic so there would not be a decrease in urine output, it is used for fluid retention so decreased weight would be appropriate.

NGN: Nurses Notes, 1800: the client is a female neonate born at 37 weeks of gestation to a gravida to party one mother, who was diagnosed with gestational diabetes following a spontaneous vaginal birth, she received Apgar scores of seven at one minute and eight at five minutes. The client weighs 8 lbs. 9 oz. and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30....

The nurse recognizes that the infant of a diabetic mother is at risk for __________________, _________________________, and ___________________________.

Hyperbilirubinemia , respiratory distress syndrome , cardiomyopathy

NGN: (Nurses Notes)1800: The client is a female neonate born at 37 weeks of gestation to a G 2 P 1 mother, who was diagnosed with gestational diabetes. Following a spontaneous vaginal birth, she received Apgar scores of seven at one minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz) and appears pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to be slightly jittery at 30min of age. Axillary temperature 96F, .....

(For each assessment finding, click to indicate whether the findings are associated with an infant of a diabetic mother or normal presentation.)

-Mongolian spot.

-Acrocyanosis.

-Jittery at 30 minutes of age.

-Blood glucose 35.

-Billirubin 7.

-Respiratory rate 80 breaths per minute.

-Apgar 7 at one minute, 8 at five minutes.

-Soft fontanelles

-Mongolian spot. (NORMAL)

-Acrocyanosis. (NORMAL)

-Jittery at 30 minutes of age. (NOT NORMAL)

-Blood glucose 35. (NOT NORMAL)

-Billirubin 7. (NOT NORMAL)

-Respiratory rate 80 breaths per minute. (NORMAL)

-Apgar 7 at one minute, 8 at five minutes. (NORMAL)

-Soft fontanelles (NORMAL)

NGN: For newborn baby.

Which six orders take priority?

A) Transfer to neonatal intensive care unit.

B) Blood glucose level.

C) Feed immediately.

D) Bolus of 2 mL per kilogram glucose 10% IV.

E) Monitor for respiratory distress.

F) Echocardiogram.

G) Contact respiratory therapy for ABG and oxygen therapy.

H) Monitor temperature every 30 minutes.

I) Keep in warmer with bilirubin lights.

J) Apply dextrose gel inside the babies cheek.

A) Transfer to neonatal intensive care unit.

B) Blood glucose level.

C) Feed immediately.

D) Bolus of 2 mL per kilogram glucose 10% IV.

E) Monitor for respiratory distress.

J) Apply dextrose gel inside the babies cheek.

NGN: For newborn baby.

(which actions are appropriate for the nurse to take at this time? SATA)

A) Keep infant in warmer with Billirubin lights to maintain temp.

B) Continue to monitor glucose levels.

C) Observe for signs of respiratory distress and monitor oxygen.

D) Tell the mother that she will need to discuss any concerns.

E) Explain to the mother that the babies respiratory rate needs.

F) Monitor temperature.

G) Informed the mother that the baby is stable enough to take.

B) Continue to monitor glucose levels.

C) Observe for signs of respiratory distress and monitor oxygen.

F) Monitor temperature.

NGN

NGN: day 2. 0630: Vitals have remained stable throughout the night. Oxygen 98% on 0.25 L per minute oxygen via nasal cannula. Mother to breast-feed in nursery on demand. Able to tolerate breastmilk. Glucose after feeding was 60, temp 97.8 F axillary when you return to warmer and Billy Rubin light. Chest x-ray and echocardiogram results were normal. Calcium and magnesium within normal limits. Direct bilirubin five. Discharge teaching initiated, with goal of discharging infant and mother on day three.

Highlight notes that demonstrate improvement.

-Vitals have remained stable

-Oxygen 98% on 0.25 L per minute oxygen via nasal cannula

-Able to tolerate breastmilk.

-Glucose after feeding was 60, temp 97.8 F axillary

-Calcium and magnesium within normal limits.

-Direct bilirubin five

The nurse discovers that an older adult client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, which information is most important for the nurse to obtain from the clients medical history?

A) length and frequency of the clients tobacco use.

B) Genetically inherited disorders of family members.

C) Frequency of laxative use for chronic constipation.

D) Ingestion of shellfish or fish oil capsules daily.

D) Ingestion of shellfish or fish oil capsules daily.

Client who underwent an uncomplicated gastric bypass surgery is having difficulty with diet management. Which dietary instruction is most important for the nurse to explain to the client?

A) To food slowly and thoroughly before attempting to swallow.

B) Plan volume controlled, evenly space meals throughout the day.

C) Sip fluids Chloe with each meal and between meals.

D) Eliminate or reduce intake a fatty and gas forming foods.

B) Plan volume controlled, evenly space meals throughout the day.

A client with an acute myocardial infarction is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response?

A) Activated partial thromboplastin (aPTT) time is two times the control value.

B) Cardiac tracing shows 1.2 MM wide Q waves half the height of the complex.

C) Guiac test of the stools is positive.

D) S3 heart sounds are present with auscultation

A) Activated partial thromboplastin (aPTT) time is two times the control value.

An adolescent client who has been treated in the past for a seizure disorder is admitted to the hospital immediately after admission the client begins to have a grand mal seizure. Which action should the nurse implement?

A) Place a padded tongue blade between the clients teeth.

B) Observe the client carefully.

C) Obtain assistance in holding the client to prevent injury.

D) Call a rapid response team.

B) Observe the client carefully.

Client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000. Which intervention is most important for the nurse to include in the clients plan of care?

A) Obtain a clients temperature every four hours.

B) Assess urine and stool for occult blood.

C) Require visitors to wear respiratory masks.

D) Monitor for signs of activity intolerance.

B) Assess urine and stool for occult blood.

A client with diabetes insipidus has an average urinary output of 500 ML of dilute urine every hour for the past four hours. Which laboratory test is most important for the nurse to monitor?

A) Urine specific gravity.

B) Capillary glucose.

C) Serum sodium.

D) White blood count.

C) Serum sodium.

The nurse is managing the care of a client with Cushing syndrome. Which intervention should the nurse delegate to be unlicensed assistive personnel? SATA.

A) Weigh the client and report any weight gain.

B) Note and report the clients food and liquid intake during meals and snacks.

C) Assess the client for weakness and fatigue.

D) Evaluate the client for sleep disturbances.

E) Report any client mention of pain or discomfort.

A) Weigh the client and report any weight gain.

B) Note and report the clients food and liquid intake during meals and snacks.

E) Report any client mention of pain or discomfort.

A client with persistent low back pain has received a prescription for an electronic stimulator tens unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?

A) Check the amount of gel coating on the electrodes.

B) Decrease the strength of the electrical signals.

C) Remove electrodes and observe for skin redness.

D) Determine if the sensation feels uncomfortable.

D) Determine if the sensation feels uncomfortable.

Before leaving the room of a confuse client, the nurse notes that a half bow not was used to attach the clients wrist restraints to the movable portion of the clients bed frame. What action should the nurse take before leaving the room?

A) Ensure that the number cannot be quickly released.

B) Ensure that the restraints are snug against the clients risk.

C) Tie the knot with a double turn or square knot.

D) Move the ties so the restraints are secured to the side rails.

A) Ensure that the number cannot be quickly released.

A client is being urgently transported to radiology for a CT scan after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube of 20 cm section. Which action is most important for the nurse to take?

A) Secure the chest tube to the stretcher for transport.

B) Keep the chest tube container below the site of insertion.

C) Administer a PRN pain management prior to transport.

D) Mark the amount of chest drainage on the container.

B) Keep the chest tube container below the site of insertion.

The nurse is managing for clients in the ICU who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding?

A) Diminished breath sounds in the right posterior base.

B) Restrained and restless with a slow volume alarm sounding.

C) High-pressure alarm sounds when client is coughing.

D) An audible voice when client is trying to communicate.

B) Restrained and restless with a slow volume alarm sounding.

NGN

????

Nurse is caring for a client with a sexually transmitted infections syphilis. The client reports having had prior sexually transmitted infections. Which response should the nurse provide?

A) Notify that persons with STDs are reported to local health departments.

B) Answer questions directly and correct any misinformation.

C) Provide counseling that most contraceptives protect against infection.

D) Discuss that partners without similar symptoms may not be infected.

B) Answer questions directly and correct any misinformation.

Which instruction should the nurse delegate to an unlicensed assistive personnel?

A) Call the pharmacy to obtain clients new antibiotic dose.

B) Observe the clients gate to determine the need for assistance.

C) Bring a sterile chest drainage unit from central supply to the unit.

D) Evaluate a clients urinary catheter for proper drainage.

C) Bring a sterile chest drainage unit from central supply to the unit.

A client with unilateral hearing loss is admitted for a schedule surgery. Which technique should the nurse use to provide education about pain relief options?

A) Speak directly facing the client.

B) Write information on a whiteboard.

C) Talk loudly into the infected ear.

D) Repeat information to the client.

A) Speak directly facing the client.

A client who is 65 kg receives a prescription for lorazepam 44 mcg/kg IV to be administered 20 minutes before a scheduled procedure. The medication is available in 2 mg/mL vial. How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest 10th)

1.4

The nurse on a medical surgical unit receives a report from a post anesthesia care unit nurse for a client who is being transferred following a right hemicolectomy. The PACU nurse reports, the client has an IV infusion of 1000 mL of lactated ringers infusing at 125 mL per hour into the left wrist with 300 mL remaining. Prescriptions and food morphine sulfate 2 mg IV every 2 to 4 hours for pain. Last administer 30 minutes ago, and aspirin 4 mg IV every eight hours for nausea, last administered 15 minutes ago. Which additional information is most important for the nurse to obtain in the report?

A) History of vomiting at home for three days prior to surgery.

B) Peripheral pulse is present with full range of motion of both legs.

C) Soft abdomen, absent bowel sounds, no bleeding on dressing.

D) Declining to take ice chips for complaints of dry mouth.

C) Soft abdomen, absent bowel sounds, no bleeding on dressing.

Entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

A) Low intermittent suction prescribe for the nasal gastric tube is turned off.

B) The urinary catheter drainage bag is almost completely full of amber urine.

C) A Hemovac drain is partially full of serious drainage and he's not impressed.

D) Oxygen has been administered via nasal cannula at 4 L per minute without humidification.

C) A Hemovac drain is partially full of serious drainage and he's not impressed.

An older adult client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high fiber foods to the client that the healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods?

A) Turn on overhead lights while giving instructions.

B) Stand behind the client to avoid intimidation.

C) Use background music to promote relaxation.

D) Provide handouts written at a 12th grade reading level.

A) Turn on overhead lights while giving instructions.

The nurse leading the care team on a medical surgical unit is assigning client care to a practical nurse and an unlicensed assistive personnel. Which activity should the nurse assigned to the UAP?

A) Change the hydrocolloid dressing to a clients venous ulcer.

B) Start an adverse event report related to a clients fall incident.

C) Empty and measure drainage from closed will containers.

D) Introduced client teaching forecast care and crutch walking.

C) Empty and measure drainage from closed will containers.

Older adult client is admitted to the stroke unit after recovery from the acute phase of an ischemic cerebral vascular accident. Which intervention should the nurse include in the plan of care during convalescence and rehabilitation.? Select all that apply.

A) Place a bedside commode next to bed.

B) Measure neurological bagel signs every four hours.

C) Play classical music in room while client is awake.

D) Section oral cavity every four hours.

E) Encourage family to participate in the clients care.

A) Place a bedside commode next to bed.

E) Encourage family to participate in the clients care.